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. 7 i APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT I// 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 `ff .3 Telephone (209) 466-6781 ) � � ; DATE ISSUED Q ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 j and the Rules and Regulations o the San Joaquin Local Health District, Job Addresses Subdivision Name Owner's Name Address Phone $x` Contractor's Name License No. ;s'�,2/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �) `' rel FOUNDATION AGRICULTURE WELL OTHER 14 ELLS• t PLTS/SUMPS 1 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 + W ❑ Public F-1 Other ❑ Delta Type of Casing.. ( - V Irrigation A rox. Eastern 9 Depth � Specifications-4 !" � ❑Cathodic Protection Depth of Grout Sealr ❑Geophysical FJ Other Type of Grout f. i Surface SealInstalled b)_ Repair Work Done ❑ Type of Pump H.P. State Work,Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTRLLATIDN ❑I REPAIR/ADDITION ('No septic tank or seepage pit permitted if public sewer is available within 200 feet.) ]nstal'Iation will serve: Residence commercial Other Number of living units: _J__- Number of bedrooms 2_ . Lot size / x p_ Character of soil to a depth of 3 feet: L VA. -445;v Water table depth is_ p r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity VQ Method of Disposal s SEWAGE SYSTEMri Distance to nearest: 4deli DESTRUCTION Foundation p rr Property Line r LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well ` Foundation Property Line -- SEEPAGE PITS [ Depth PL�) Size Y Number SUMPS 1J Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 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 applicant mu 11 fo all re red inspections. Complete drawing on reverse side, Signed X Title: Date: �G7 DEPARTMENT USE LY Application Accepted by/rZ!4� Area / ❑ Stk 466-6783 Additional Comments: Lodi 369-3621 Pit or Grout Inspection bDate ❑ Manteca 823-7104 Final inspection by / r { 'Date j ❑ Tracy 835-6385 Applicant - Return all copies toEnvironment�ellth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO y tt� - Il -Z3 233-1133f EH I3-24 REV. 10/82 10/82 500 14-26 °i