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r. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 Telephone {209} 466-6781 DATE ISSUED 0-'1 .3-$3 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 a Re lation of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name z. r t4 Address Phone Contractor's Name I E f: \1Q ftLI } VA Lljcense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [f DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 3 •DISPOSAL-FLO. --PROP.-LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIDN SPECIFICATIDNS r , Industrial Open Bottom Manteca Dia. of Well Excavation �•1 ❑ Oamestic/Private Gravel Pack Tracy -Dia; of Well Casing - - 11 Publ is ❑Other Delta Irri ation Type of Casing U 9 Approx. [] Eastern Depth Specifications f-ICathodic Protection P � Depth of Grout Seal Geophysical Type -af'Grout LJ Other Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIDN ICil REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is T� available within 200 feet.) Installation will serve: Residence Commercial _ Other � Number of living units: J— Number of bedrooms '�^ Lot size -7 D X D.0 O/ Character of soil to a depth of 3 feet: -SR Water table depth SEPTIC TANK Type/Mfg C Capacity )a o 0 :No. Compartments a� _ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Sowtoundation Property Line DESTRUCTION ❑ LEACHING LINE U No. & Length of lines , Total length/size `)C FILTER BED 6J,--8istance to nearest: Well ,Abo-- Foundation _30 Property Line SEEPAGE PITS ❑ Depth Size Number' SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D na�in.rrr- 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 hi ' or sub-contracting signature certifies the following: "I certify that in the performance of the work for which �t is permit is s I shall lay persons subject to workman's compensation laws of California." The app us call all ui in tions, Complete dra g on re sa-side Sig Title; Date: M ONLY Application Accepted b Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 10 Tracy 835-6385 s, Applicant - Return all copies t • nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3 EH 13-24 REV. 10/82 r /] ^� � 10/82 500 14-26 1