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�a: 3 D APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELT014 AVE., STOCKTON, CA PERMIT NO. Tele`ph8ne (209) 466--6781 2 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 wort. 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. Job Address .3qW_ S, s•7 Subdivision Name ��CfSrlAlis 1-0 CO j Owner's Name 4A 1)1"deIu-1 ESf/a[4.44&Address Ar Phone 3�' Contractor's Name p I, �9 License No. �'�� Phone . fig; 3`77I TYPE OF WELL/PUMP WORK: NEJ WELL }-WELL REPLACEME3Tx ❑ DESTRUCTION ❑ L� PUMP INSTALLA_TI'ON—Ej--SYST M,REPAIR TMs ❑ OTHLR ❑1 i DISTANCE TO NEAREST: SEPTIC TANK r SEWER L NES DISPOSAL FLD. PROP. LINE FOJNDATION 1 R AGRICULTURE WELL OTHER WELL PITS/SUMPS d INTENDED USE TYPE:OF WELL PROBLEM AREA "CONSTRUCTION SPECIFICATIONS I❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Domestic/Private ❑Gravel Pack ._ ` .Tracy Dia. of Well Casing ` Public [] Other # e ❑ Delta 9 f i Type of Casin LjIrrigation Approx. : ❑Eastern Specifications ❑ Cathodic Protection Depth 4 t Depth of Grout Seal ❑Geophysical a �"�A Type of Grout 1❑Other _ c 'F"Surface Seal;Installed by s s a W6 4 =1i -State Work Done { l 1 k 'Repair"Work'Done ❑""Typeof Pump H.P. W Well Destruction ❑ Well Diameter Sealing Materialt(top 501) J Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION:L1 REPAIR/ADDITION 1[e(No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence commercial _ Other Number of living units: �-' Number of bedrooms: Lot size =xi 3 ,_ Character of soil -to a depth of 3 feet:_ LA Water table depth f No. Compartments SEPTIC TANK ❑ Type/Mfg ." Capacity PKG. TREATMENT PLT. ❑ Type/Mfg ' + Capacity Method of Disposal SEWAGE SYSTEM Distance to nearestWe]1 .--Foundat pnw Property Line DESTRUCTION t a' LEACHING LINE No. & Length of Sines _� = � Total length/size FILTER BED ❑ Distance to nearest: Well ( �^ Foundation Property line SEEPAGE PITS Depth : Size i Number SUMPS ❑1 Distance to:nearest- Well ! �� Foundation Property Line DISPOSAL PONDS ❑ k '�`} i I hereby certify that 1 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 foilowing: "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 t 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 employlpersons subject^•to workman's compensation laws of California." The applicant must call for 11 required ins'pec ion's` Complete dr wing�o�n—reverse side. r� a Signed R_ ��r - —y Title: I�t. I _ Date: �y� "'d FOR.DEPA TMENT'U /ONLY ; Application Accepted byl.�a Area {} ❑ 5tk 4fi6-6781 E Additional Comments: _ ' / ❑ Lodi 369-3621 Pit or Grout Inspection b `3 Date ❑ Manteca 823-7104 Final Inspection byDate $�[ ❑ Tracy 835-6385 Applicant - Return all copies to: nvironmertI1 Health EPermit/Services 1601 E. Haze]ton Ave., P.O. Box 2009, St k., CA 95201 r FEE BASE AMOUNT' DUE AMOUNT REMITTED RECEIVED BY -p DATE p �q 2PERM�IfT N0. INFO 10/S2 500 EH 13-24 REV. 10/82 l 14-26