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APPLICATION FOR PERMIT U SAN IOAQUjN LOCAL HEALTH DISTRICT rr 1601 E. HAZEL70N AVE., STOCKTON, CA PERMIT NO, 3 E`L'i # J Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �}.:.� .�1 `q:.�•Ja _ '`xi,� (Complete in Triplicate) HEALT11-1 D1 Application is hereby ,,difto the San Joaquin Local Health District for a permit to construct andsew 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 Regulations of the San Joaquin Local Health District, Jab Address 006 Subdivision Name �)o Address X ova C, Ch Phone 0 Owner's Name -1/1 1 .- ,� � .� Phone y6' 9C.,zS Contractor's Name +. License No. -1 7 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U F P,�UMP INSTALLATION SYSTEM REPAIR OTHER f DISTANCE TO NEAREST- SEPT 1'C TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fig "INi£NDE4'USE'^ = TYPE"OF`'WEtL"-i�=PROBLEki AREA- - CONSTRUCTION SPEGIFIC-ATIONS. i� trial U Dpen Bottom Manteca Dia. of Well Excavation I l 1 Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing i Public Other Delta Type of Casing Lj Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done F Typef'of Pump H.P. State Work Done 91,11 - y f " Well Destruction U Well; Diameter Sealing Material (top 50') Depth Filler Material (Below 50') O F Cy TYPE OF SEPTIC WORK: NEw INSTALLATION U REPAIR/,ADDITION L {No septic tank or seepage pit permitted if public sewer is �Mavailable within 200 feet.) -Installation will serve: Residence _ Commercial _ Other Number of bedrooms size V, Number of living units: �. Lot _ Water table depth Character of soil to a..depth of 3 feet: SEPTIC TANK L! Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U : No. & Length of lines Total length size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE P1T5'"'�' De`pfh �-- Size - Number Ll1SUMPSDistance to nearest: Well Foundation Property Line I. DISPOSAL PONDS ❑' - [ hereby certify, that L'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 perform ante 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, 'd shall employ persons subject to workman's compensation laws of California." hh The applicant must calli-For all required inspections. Complete drawing on reverse side. }} Signed XA& 212 Title: Date: DEPARTMENT USE ONLY Area [�Stk 466-6781 Application Accepted by Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection by Date Final Inspection by Date Z ❑ Tracy 835-6386 Applicant - Return allcopies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a 10/82 500 EH 13-24 REV, 10/82' Y 14-26