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t APPLICATION FOR PERMIT SAN JOAQUiN° LOCAL HEALTH DISTRICT Q `� � y 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. U-3'—� (, Telephone (209) 466-6781 PERMIT EXPIRES 1 'Y EAR DATE ISSUED—?FROM DATE ISSUED , (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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 E and the Rules and Regulations of the San Joaquin Local HealthDistrict. Q I Job Address 53 L W }-, An�S Subdivision Name [ ", - 117 ' Owner's Name �ArJ,2 y i."� / 1L � Address S,52_ IVJ'r.� rfl0 Phone Contractor's NameLicense Na. f 9 3 Y Phone _' J .-774' TYPE OF WELL/PUMPr WORK_ 'NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIONSYSTEM REPAIR OTHER [J- DISTANCE DISTANCE TO NEAREST: SEPTIC TANK' s SEWER LINES s DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM'ARFk w CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ® Domestic/PrivateGravelF Pack Tracy Dia, of Well Casing L7 Public Ej Other ' ` Delta Type of Casing 7 irrigation Approx. Q Eastern Cathodic Protection Depth Specifications Geophysical Depth of Graut.Seal LJ Other Type of Grout ` Surface Seal Installed by Repair Work Dane;W Type of.Pump 6l_ H.P. _ State Work Done, Wel] Destruction U Wel I _Diameter ' Sealing Material (top 50') Depth t Filler Material (Below 50') TYPE Of SEPTIC WORK: NEW INSTALLATION [_� REPAIR/ADDI•TION J (No septic tank or seepage pit permitted if public sewer is Y 5 , ., available within 200 feet.) , Installation will serve: Residence i Commercial t Other Number of living units: Number of"bedrooms'-"- +" ,Lot' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK EJ Type/Mfg a Capacity No.°Compartments PKC; TREATMENT PLT. Type/Mfgf,1 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 1 'SEEPAGE PITS ❑ Depth Size Number r SUMPS l-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. j Home owner or licensed agent's signature certifies the Jol1owing: "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 workmant 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 must call for all "equ a insp ctions. Complete drawing on reverse side. : Signed °tle: _ pabJ' _ Date: FO ENT USE ONLY ¢" Appl ication epted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: , Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO y5� 33 �3 $3- 1 EH 13-24 REV. 10/62 10/82 500 14-26 I ;r