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APPLICATION FOR PERMIT ry SAN JOAQUIN LOCAL HEALTH DISTRICT q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 S [ Telephone (209) 466-6781 DATE ISSUEO PERMIT EXPIRES 1 YEAR FROM DATE I55UED (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. 4 Job Address ,:� Subdivision Name Owner's Name Lr, Address Phone Contractor's Name CrIQ_ License No. ._ Phone TYPE OF WELL/PUMP_WORK: NEW WELL ] WELL REPLACEMENT DESTRUCTION❑ PUMP INSTALLATION [] SYSTEM REPAIR OTHER ) x; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES + DISPOSAL FLO. PROP. LINE FOUNDATION I! AGRICULTURE WELL .s"+' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑Manteca s Dia. of Well Excavation E]Domestic/Private Gravel Pack Q Tracy Dia. of Well Casing Public ElOther �1 E]Delta .- Type of Casing U Irrigation Approx. [ Eastern� � Specifications 1 0 Cathodic Protection Depth 1 Depth of Grout Seal k -p Geophysical 91 � Type of Grout ` Other '$ Surface Seal.Install,ed by Repair Work Done Q Type of Pump H.P. State Work Done , Well Destruction_- Well Diameter Sealing Material (top 501) s Depth Filler Material (Below 501) __ i ON TYPE OF SEPTIC WORK: NEW,(NSTALLATIONY�., REPAIR/ADDITION U (No septic tank or seepa4q pit permitted if public sewer is U i available.within 200 feet.). Installation wiPl serve: ResidenceCommercial _ Other Number of living units:'T Number of bedrooms �� .� Lot size �� t Character oflsoii to a dept R of;3_feet:'_ /Id�� : . Water table depth 1 SEPTIC TANK Type/Mfg` i� �� Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg II Capacity Method of Disposal Septic Tank Dista ce toTnearest: Well Foundation Property Line Destruction 13 LEACHING LINE Nr No. & Lengthiof.lines — _' Total length/size yQ ( ' FILTER BED Distance to.nearest: Well �.f/ Foundation Property Line SEEPAGE PITS ❑ Depth of_. Size Number , SUMPS U Distance tonearest: Well Foundation Property Line DISPOSAL PONDS D 7 F , 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 agent1•-$1.signa6re certifies the following: "I certify that in the performance of the work for which this permit is issued; .1-,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 fallowing: "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 cal for required inspections. Complete drawing on reverse side. Signed X Title: Date: �' - a ,I ; FOR DEPARTMENT USE ONLY 4 Application ccepted by Area 2 �3 l ❑ Stk 466-6781 k Additional Comments: ' .:M{ ❑ Lodi 369-3621 # Pit or arouOInspection by a?.. Date 51'e'nteoa 823.7104 Final Inspection by Date (] Tracy 836.6388' Applicant Return ell-_copl.es_ o,.—Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 c FEE BASE AMDUNT DUE11 AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' INFO ....- EH-13.24--REV•;.„10/B2-'"''"`Y - 10/82 500 14-26 Ver