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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3 Telephone (209) 466-67.81 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit-to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address �d 3 � Qr�,) f� - Subdivis �Z-y Owner's Name Address � tp - Phone Contractor's Nam License No. 3 Z��? _ Phone QlJ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0 DESTRUCTION U . < « PJMP,INST.ALLATION SYSTEM REPAIR �. - OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE A. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial U Open Bottom F-I Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing t D Public G Other Delta Type of Casing V Irrigation. Approxi' E] Eastern Specifications i ❑ Cathodic Protection Depth Depth of Grout Seal j�Geophysical :g i LType of Grout U Other r Surface Seal Installed by Repair Work Done Type,of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501)� Depth Filler Material (Below 50')' r 1 F _ _ / TYPE OF SEPTIC WORK: NEW INSTALLATION U '�R DDITION (No septic tank or seepage pit permitted if public sewer is `available within 200 fe .)��-q7 Installation will serve: Residence Commerc1.61 , Other, 4$ Lz/te rim s'-� fl_^1 Number of living u015; Number of bedrooms-� -__' Lot size 1 ! -�& ` Character of so-49 to a depth of 3 feet: CD Water table depth b2o t i SEPTIC TANK Type/Mfg ' ; -Capacity No. Compartments PKG. TREATMENT PLT .E] Type/Mfg a ty Method of Disposal SEWAGE SYSTEM Distance t ares el ound on Property Line i DESTRUCTION ❑ "r w Y y ` 4i LEACHING LINE U No., & Length of lines �" uTotal`lengfh/siie t FILTER BED tance to nearest: Well Foundation Property Line r SEEPAGE PITS t, Depth 4 Size ' SUMPS iU Distance to nearest: Wellid)6 if 7=oounndation ! Property Line .� DISPOSAL PONDS Q I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i ordinances, state laws,_and._ru.les:and,regulatigns of the San Joaquin Local Health District. el I -Home-owner'or licensed agent's signature certifies the-foll`owing:'"i"cert'ify that"in'the'performance of the work for which this permit is issued, I shall not employ any person in such manner as to,become subject to workman t compensation laws of California." Contractor's hiring or sub-contracting signaturelcertifies�the following "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's-compensation laws of California." I The applicant m ca 1 IffooJr/all1 e fired inspections. Complete drawing on reverse side. / ' Signed X �.<%a�Y/ / Title: Date: I FOR DEPARTMENT USE ONLY l Application Accepted by Area i�f� ---- �tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection ' Date LL Manteca 823-7104 -11HAEFinal Inspection by Date d L Tracy 835-6385 Applicant - Return all copi to: En viro ental Healt Permit/services 160 E. H zelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT-REMITTED RECEIVED BY DAT^Ep PERMIT NO. INFO EH 13-24 RFU. 10/82 10/82 500 14-26