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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT € 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. SS 3—J'9Q Telephone (209)466-6781 �l DATE ]55UE0 —i{ �3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r eA T`�lQ�i� SY (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 the San Joaquin Local Health District, Job Address N pYI}fit o�' i��o �Rtlesino_�3Lme Owner's Name ^��o-�-� �,� �� Address k_,- ti7a, �d _ Phone g3C—,-j Z� Contractor's Name License No. Phone f TYPE OF WELL/PUMP WORK: NEW`WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION f. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ OpenlBottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing �] Public Other ❑ Delta.:. Type of Casing LjIrrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 3 Geophysical k 1' Type of Grout ❑Other Surface Seat Installed by Repair Work Done Type of Pump- H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ D "Depth Filler Material (Below 50') 1 'd TYPE OF SEPTIC WORK: NEW INSTALLATION ] REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation williserve: Residence K_ commercial Other Number of living units%_J__ Number of bedrooms 2 -,. . Lot size _ #tG, S `` Character of soil to a depth of 3 feet: An A , LWater table depth np t Type/M } Capacity 12 CJC� No. compartments TANK7ri PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance: to nearest: Well 1s4:� Foundation 1(� Property Line _ S DESTRUCTION ❑ I LEACHING LINE No. & Length of lines Total length/size A/Q t FILTER BED ❑ Oistance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 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 E 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 S permit is issued, I shall not employ any person in such manner as to become subject to workman Is 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 t callor 11 required 'nspections. Complete drawing on reverse side. { Signed X / Title: "nepDate: F ARTMENT USE ONLY i CStk 466-6782 i Application Accepted by � Area � ❑ , Additional Comments_ f Lodi 369-3621 Pit or Grout Inspection by oeDate ❑ Manteca 823-7104 Final lnspection'by Date ::.T77/ Tracy 835-6385 Applicant - Return all copies tol Environm al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2039, Stk., CA 95201 x FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO } SLA -5, EH 13-24 w REV. 10/82 10/82 500 14-26