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' APPLICATION FOR PERMIT SEP 19 1383 ,.. SAN JOAQUi%' LOCAL HEALTH DISTRICT ,,ll 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3` O3 6 N'?/hQVM LOCAL,, Telephone (209) 466-6781 M DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , 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 Regulation af,the,San,Joaquin Loca Health District. Job Address 13 � Fj _ Subdivision Name ` Owner's Name Address } . , C�1_ Phone f33o6---7y'0? Contractor's Name jf bh � .r?If.i License No. ._9 QCY1 Phone TYPE OF WELL/PUMP 14ORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f„ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r1V" Domestic/Private El Gravel Pack E] Tracy Dia, of Well Casing lJ ❑ Public ❑ Other ❑ Delta Type of Casing irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump S`.)4 H.P. j State Work Done Yk,(Orry Zg--- F Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler-Material (Below 501) 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if•public sewer is (n available within 200 feet.) � ! Installation will serve: Residence _ Commercial Other IrD Number of living units: Number of bedrooms Lot size Character of-soil to a depth of 3 feet: Water table.depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 agent'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, I shall employ persons subject to workman's compensation laws of California." The appllgfTnt must cal for 41 required inspections. Complete draaw��ing on reverse side.' � Signed x � � Title: 6" 1 Date: �� -� ENT NLY Application Accepted b Area �_ ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection y Date �Ao Manteca 823-7104 , Final Inspectioh by Date #t ❑ Tracy 835-6385 Applicant - Return all copies to: Environments ealth Permit/Services 1661' E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 Rev. 10/82 � � rr 10182 500 14_26 r ,�