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APPLICATION FOR PERMIT SAN ,IOAQUIN LOCAL HEALTH-DISTRICT I! 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 Telephone (209) 46616781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i� (Complete in Triplicate) I� a 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. 4 Job Address �3L -3 1, I��i _� 0/��P. LAA16 E Subdivision Name �L Owner's Name /-A 74 Address II Phone Contractor's Name License.No. Phone — Ob TYPE OF WELL/PUMP WORK: NEW WELL L WELL REPLACEMENT E] DESTRUCTION �� W PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER 1 DISTANCE TO NEAREST:SEPTIC'TANK_ i SEWER LINES T DISPOSAL,FLa _PROP. L1NE Q FOUNDATION AGRICULTURE WELL OTHER WELL !! PITS/SUMPS 06 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial U Open Bottom Ej Manteca Dia. of Well Excavation ;: { IJ Domestic/Private E Gravel Pack { Tracy Dia. of Well Casing 'I 1 Public f-1 Other Delta Type of Casing r ; L i Irrigation Approx. Eastern r f Depth Specifications Cathodic Protection p Depth of Grout Seal LI Geophysical LJ Other Type of Grout r Surface Seal Installed by n Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION ✓ D (No septic tank or seepage pit permitted if public sewer 'is available within 200 feet.) Z Installation will serve: Residence tom, Commercial Other Number of living units: _ Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [� Type/Mfg (1- �Capacity—J —compartments PKG. TREATMENT PLT. [] Type/Mfg - .Capacity Method of Disposal SEWAGE SYSTEMi! Distance to nearest: Well Foundatioria % Property Line �a DESTRUCTION s + LEACHING LINE J M � No. & Length of;1 in.es f Total—1•ength/size /767 vir 2. FILTER BED Distance to nearest: Well f. / Foundation 2i�/ Property Line SEEPAGE PITS Depth c Size Number Z II SUMPS L Distance to nearest: Well _7__36P Foundation //p 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. !I 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 must call for all required 1'pspec tions. Complete drawing on reverse side. Signed X Title: ��,-yj� i Date: F A 7MENT USE ONLY II ` Application Accepted by _ . ��/ Area � - - Stk, 466-6781 - Additional Comments: Lodi 369-3621 i Pit or Grout Inspection by AllDate' U Manteca 823-7104 Final Inspection by Date /D 3 �� L Tracy 835-6385 Applicant -Return all copies to: Environmental Health Permit/Services 1601`E. Hazelton Ave., ':P.0, Box 2009, Stk., CA 95201 I� FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATED PERMIT NO. INFO - 30 3 83- 1081 : EH 13-24 REV. 10/82 10182 500 14-26 '.• ��