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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. 3 3-lU V 4 DATE i55UfD �� —7 N-17 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 it compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and•the Rules and Regulati ns of th Jan Joaqu"n Lo al Health District. Job Address�y [� 1, 'L.�l[Z� Subdivision Name Owner's Nam<54A_1"_%" Qt1.1_JJL;1A Address hXXid Phone, 1(0-'7 - 75 f' j Contractor's Name s C� License No. Z 2._ Ce Phone & 4 . TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ,0]STANCE .TO•NEAREST:_SEPTIC TANK:-.'. SEWER LINES DISPOSAL FLO. PROP. LINE F ;;,FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing [__1 Public CJ Other ❑ De3ta Type of Casing V Irrigation Approx. [] Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑ Geophysical Type of Grout ❑ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wel-1 Diameter Sealing Material (top 50') _ Depth- Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONo s ptie nk or seepage.,pit permitted if public sewer is --available wi t , 200.eet. ) Installation will serve: R silence Z-<�Commercial Other' �C%Ctt-sy .•,J/ r Number of living units: Numb6r of b d ooms' * Lot size Character of soil to a depth of 3 feet: l Water table depth SEPTIC TANK Type/Mfg .. Capacity !J P No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg I Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well, Foundation Property Line DESTRUCTION �t LEACHING LINE ❑ No. & Length -df i{l'nes4` }' :Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS ❑ Depth Size 'Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a � •I hereby certify that I have prepared this application and that the work will be done in accordance with San"Joaquin county ordinances, state laws, and rules and regulations_of the San Joaquin Local Health District. Home owner or licensed agerit''s signature certifies the following: "I certify 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 � compensation laws of'California." Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." The applic t must cal or' 11-re'quirT einspections. Complete drawing on se side. Signed X Title: f Date:, 0 PARTMENT USE O Y App," ation Accepted b Area _n,7� Stk 466-6 1 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date i L7 Tracy 835-6385 Applicant - Return all copi s to:. Envi onmental ealth Permit/services 1601 E. Hazel n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO (0 6 EH 13-24 REV. 10/82 10/82 500 14-26