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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 2 C� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 f ti_ARENCi 3 SEPTIC & SEWER SERVICE Telephone (209) 466-6781 253 SC. 0,0 .4 SiCclgnJ�j, Calif. 9,5205 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED Ph.4 209 ftnlracto�'s Lic.*?F'17� (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� G h-'EF Rs -S_f^ Subdivision Name _, � 9 / Owner's Name (j Address Phone _ Contractor's Name (:' License No. Phone OrL-,7 11 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT W �] � DESTRUCTION � I PUMP INSTALLATION SYSTEM REPAIR OTHER �1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i 1 -1 Industrial Open Bottom Manteca Dia, of Well Excavation D Domestic/Private E] Gravel Pack Tracy Dia, of Well Casing 17 Public Ej Other Delta D IrrigationType of Casing ApEastern Cathodic Protection Deeptthh Specifications U Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Dane Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler-Material (Below 50') Q TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: ResidenceCommercial _ Other available within 200 feet.) Ile Number of living units: —/— Number of bedrooms Lot size Character of soil to a depth of 3 fe t; - Water table depth SEPTIC TANK De' Type/Mfg ,�. Capacity y41,ZaJqo. Compartments f PKG. TREATMENT PLT. Type/Mfg Capacity Method of'Disposal Distance to nearest: Well Foundation r Property Line , o LEACHING LINE No. & Length of lines J` Total length/size FILTER BED, Distance to nearest: Well ,� Foundation _,,,�r _ Property find SEEPAGE PITS Depth s—.� Size F_/_1 plumber 0 _ SUMPS !J Distance to nearest: Wel l2Z.C/� Foundation le 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 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 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 st all for all rreq 'red in ections. Complete drawi o :-_r terse de. Signed X Title; Date: _gj �l Ir FOR DFRT EN7 O QASLY Application Accepted by ��47.t^•� Area , elyT Stk 466-6781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date _Xrj M Manteca 823-7104 Fin nspection by Date 5-,,V-F 3 EJ Tracy 835-6385 Applicant - Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE D RECEIVED BY DATE PERMIT N0. INFO � 3-31 EH 13-24 REV. 10/82 10/82 500 14-26