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T'G 4Y APPLICATION FOR PERMIT f ai► is .�+ SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1! 49� q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, 0 3-3 Telephone (209) 466-6781 DATE I55UE03 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 f the San Joa u.ir�Local Health District. 3 t Job Address /� /9JII C .p Subdivision Name Owner's Name 31 p Address Phone Contractor's Name , License No. Phone r TYPE'OF WELL/PUMP WORK: -NEW WELL � ��]• -WELL REPLACEMENT-[]r r�DESTRUCTION [f r� '� QJJ PUMP INSTALLATION (� SYSTEM REPAIR ❑ OTHER 4 DISTANCE TO NEAREST: SEPTICTANK SEWER LINES DISPOSAL FLD. PROP. LINE ! ° FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS -INTENDED USE 4 4 N TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS11 i 1� industrials 0 OpenlBottom ❑Manteca Dia, of Well Excavation # i Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing I Public a Other Delta [ ti ; Type of Casing Li Irrigation a F Approx. Eastern Cathodic Protection !M DepthLl Specifications , Depth of Grout Seal Geophysical I' Other Type of Grout II Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) r Depth ' Filler flateriall {Below 50') 9J E TYPE OF SEPTIC WORK: NEW INSTALLATION 17,2 REPAIR/ADDITION-U'l(No septic tank or seepage pit permitted if public sewer is AT available within 200 feet.) Installation will serve: Residences -�.Comnercial�.... Other Number of living units: Number of bedrooms l� Lot size R I Character of soil to a depth of 3 feet: l - Water table depth ( SEPTIC TANK ElType/Mfg Capacity Ca No. Compartments 2- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance toynearest: Well /;�J7 Foundation Property Line1`L5 w LEACHING LINE 52 No. & Length of lines - - -1 Total length/size FILTER BED . ❑ Distance-6o nearest: WellFoundation / J Property Line ^ { t r k SEEPAGE PITS— E!1 Depth "� SizeFfumber'"'""~�"""�" ' SUMPS U Distance to nearest: Well Foundation-,r.......�.�:..�Property.3Line DISPOSAL PONDS, y 1 yam. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county F 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 whichthis permit is issued, I shall"not'employ'any person in such manner as to become subject to workman§ 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." Th9 applica mustca fo'' a fired pections. Complete drawing on reverse side. �Jr Signed X Title: _ Date: PARTMENT USE ONLY w� Application Accepted by Area d" r [} Stk 466-6781 Additional Comments, ZW Lodi 369-3621 Pit or Grout Inspection by, Date Q Manteca 823-7104 Final Inspection by;�, I. Date C] Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 .c FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f 3° EH 13-24 REV. 10/82 11 10/82 500 14-2b "�