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l APPLICATION FOR PERMIT I > SAN JOAQUIN LOCAL HEALTH DISTRICT 1111iii 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. I II Telephone (209) 466-6781 DATE ISSUED ' � PERMIT EXPIRES I YEAR FROM DATE ISSUED V', (Complete in Triplicate) i 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 I and the Rules and Regulations of the San Joaquin Local Health District.. Job Address 3a 04 �`' /�V Subdivision Name Owner's Name - 1/A�LP� G7-4,We>'Address 3.ZOO 4E, cs'/,I i.4e Phone Contractor's Name .61;. icense No. lLd`�`�d Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES { DISPOSAL 'FI . PROP. LINE FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSi ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of:We111Excavation +r`.'r y ❑ Domestic/Private F-1Gravel Pack ❑Tracy Dia. of Well casi,gg- c Public Other-.t, # ❑Delta15 Type of Casing F ❑ Irrigation Approx. []Eastern Specifications 1 ❑ Cathodic Protection Depth Depth of Grout Seal l( VU Geophysical Type of Grout ` ❑Other Surface Seal Installed by t Repair Work pone ❑ Type of Pump H_P, State Work Done C Well Destruction LJ Wei l Diameter Sealing Material (top 50') ` Depth Filler Material (Below 50') r mm TYPE OF SEPTIC WORK: NEW INSTALLATION [} REPAIR/ADDITION !N (No septic tank or seepage pita pei ableed if publicfsewer iwiths Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of sail to a depth of 3 feet: F r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity -.F No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity j Method of Disposal Distance to nearest: Well Foundation Properfy_Ijne LEACHING LINE P11 No. & Length of lines ,3 /C�a ' Total length/size kFILTER BED ❑ Distance t0 nearest: Well Foundation / Property Line / d O ` + / SEEPAGE PITS [] Depth Size Number SUMPS U Distance to nearest: Well Foundation L Property Line ' DISPOSAL PONDS ❑ �" - - t s.w - '� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county is ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. f 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 1s 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 applicant mus call for 11 required inspections. Complete drawing on reverse side. ,W Signed X_ �C/ -_ Title: ' Date: x 0-g-y F PARTMENT USE ONLY Application Accepted by Area —�.! ( 5tk 466-6781 , Additional Comments: V Lodii 369-3621 Pit or Grout Inspection b Date -� El Manteca 823-7104 F Final Inspection by Date EN q-$3 ❑ Tracy 835-63857 Applicant - Return all cop to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO, <at EH 13-24 REV. 10/82 l� 10/82 500 i 14-26 -