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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE`., STOCKTON, CA PERMIT NO. Q 3 y \\ 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 and the Rules and Regulations of tU San Joaquin Local Health District. /J Job Address Subdivision Name C Gf Owner's Name _ fz Address 41701 fJ Phone Contractor's Name License No. j' Phone 361P;fr.V TYPE Of WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑f Industrial U Open Bottom Fj Manteca Dia. of Well Excavation LJ Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing I—] Public F-1 Other F-1 Delta Type of Casing F-1 Irrigation Approx. E] Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 1 Geophysical OQ Type of Grout [_1OtherSurface Seal Installed by Repair Work Done E] 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 INSTALLATION ❑ REPAIR/ADDITION �JNo septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: I_ Number of bedrooms �_ Lot size GL-,. o1 Character of soil to a depth of 3 feet: f�Q Water table depth �+ r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines y[) Total length/size �T 6 FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ciy- Depth 2li Size a Number f SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 workmans 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 mplo persons subject to workman's compensation laws of California." The applican ca for re ired inspections. Complete drawing on reverse side. �j Signed X Title: �'�' /t,6,— Date: / FOR DEPARTMENT USE ONLY plication Accepted byr Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by 6/Mi Date ❑ Tracy 835-6385 Applicant - Return all copies to: Envi ental lt eah Permit/Services 160 E. H zel! Ave., P,O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE�j F PERMIIT NO. INFO3 PERM; EH 13-24 REV. 10/82 10/82 500 14-26