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Y I l APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. $3 "-39 Telephone (209) 466-6781 � 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 lk and the Rules and ReguI ti9ns�f the San Joaquiinf l/ocaal�rHxealth District. {)L r Job Address /• 7 �(/�/!!I�K� 6- Cd Subdivision Name 4 Owner's Name Ad?LX�-/• G' _L► Address Phone — 7 13 91 License No. ..j Phone Contractor's Name � /�- 15 6` y 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 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom J7 Manteca Dia. of Well Excavation ❑) Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing ` ❑ 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 H.P. State Work Done C� Well Destruction ❑ Well Diameter Sealing Material (top 501) Depths Filler Material (Below 50') V" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) t Installation will serve: Residence Commercial i Other I 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 r. Distance to nearest: Well Foundation Property Line (,n DESTRUCTION i LEACHING LINE No. & Length of lines — Total length/size dQ X d b FILTER BED ❑ Distance to nearest: Well rS l_ Foundation Property Line SEEPAGE PITS Depth .S - Sized Number ! SUMPS ❑ Distance to nearest: Well L Foundation - .p f Property Line 4 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 i issued, I shall employ persons bject .to workman's compensation laws of California." The appli t u call fo all r ed i ti s. Comple dr �nrev�erse de.• t Signed Title: Date: 0 EPARTMENT USE ONLYAoki ` Application Accepted y - Area �-. ❑ Stk 466-6781 �a Additional Comments: n 369-3621 Pit or Grout Inspection by at � ❑ Manteca 823-7104 Final Inspettiori by Date ❑ Tracy 835-6385 ^ Applicant.- Return all copies to: Environmental Heal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95202 G FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO &S 1!F113 Cl,me F; '4 10/82 500 4 EH 13-24 REV. 10182' 14-26