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APPLICATION FOR PERMIT SAN JOAQU;N LOCAL HEALTH DISTRICT p c 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NC, d 3 -3 Telephone (209) 466-6781 ty I� 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 44 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 Regulations of the San Joaquin Local Health District. Job Address �2.0 1 (,,L%/"A , s I1/Subdivision Name 4 Owner's Name E,�, 1"1titR'�1'tY Address iSi1, GR�FFEW 't a1VT _ Phone .f "'Z, P Contractor's Name �',M, �}��,� �"E(�u`p. License No. Phone 1. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALOrATION SYSTEM REPAIR OTHER 3 RISTANCE TO NEAREST: SEPTIC TANK ��.d'� SEWER LINES DISPOSAL FLD. PROP. LINE � t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE kt TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS $ v J I Industrial `A r i f a U Open Bottom � Manteca Dia, of Well Excavation (� ��' Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing (� PublicOt/er Delta ' Type of Casing .t-ro-ro F L i irrigation k '�.p� Approx. Eastern Depth SpecificationsfZ.. Cathodic Protection p Depth of Grout Seal Geophysical L_J Other Type of Grout ��"�gh.M 6R.A)1�r Surface Seal Installed by Repair Work Done ❑ Type of,Punp H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 3 Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sealer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of,lwing unili:�__ Number—of""bedraams� Lot"size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E] Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Type/Mfg .1 Capacity Method of Disposal r. SEWAGE SYSTEM Distance to nearest: Well "' r •Fcurdation Property Line ' DESTRUCTION . F LEACHING LINE U No. & Length of lines ' Totalflength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line gP. SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line ; a 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. , a Home owner or licensed agent's.,signature certifies the following: "I certify that in thei"performance of the work for vihi'ch?this ; permit i,s issued, I shall not employ any person in such manner as to become subject tolworkman� compensation laws of California." Contractor's iring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit issued, I shall emplo persons subject to workman's compensation laws of California." The applican ust call r all red in ections. Complete dr Ing on reverse s'de. Signed ? Title: . . �.r Date: S> >R1L �S AM 4 a FOR DPARTMEN.T USE ONLY II Application Accepted by Area- € "" A�µStk - 466-6781-.-1 s Additional Comments: ❑ Lodi 369-3621 t 4144 or Grout Inspection by i Date �'` �3 Manteca 823-7104 1 Final Inspection by Date "/D Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CJ 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVEDBYDATE PERMIT�N�O. INFO 00 344, q L�.J-�3 93 � EH 13-24 REV. 10/82 10/82 500 14-26