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APPLICATION FOR PERMIT w , ". !M SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0 Q 3 Telephone (209) 466-6781 DATE ISSUED� �Z PERMIT EXPIRES I YEAR-FROM DATE ISSUED �I ,'. „• (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 ND. 1862 for well/pump and the Rules and Regulations of th San Joaq in Local Health District. Job Address /,il� s S division Name i Phone Owner Is Name /U , e Address �69- 3 i1 Contractor's Name License No. -x S �' 3 Phone TYPE OF WELL/PUMP WORK: Id NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ t PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANKSEWER,LINE5 DISPOSAL.,FLD. PROP.:LIKE w"ftl ��A, - .. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS., , Industrial f ❑OpenlBottom ❑Manteca ' Dia. of Well Excavation Domestic/Private iE Ej GravelkPack Tracy, �Oia. of Well Casing 3•�► Public 0 Other " [] Delta 'Type of Casing Lj Irrigatiion NApprox. ��Eastern Specifications Cathodicrotection II Depth Depth of Grout Seat 1 w" Fk L�Geophysical �' �#.`� t .£ -Type of Grout _ OtherY�� / ' Surface Seal Installed by,, I Repair Work}Done 0 . Type of Pump P. y+ �'_ State Work Done Well Destruction ❑ Well' Diameter . Sealing Material (top!50') eF - . Depth Filler Materia ( 41;w 50')i TYPE OF SEPTIC WORK: NEW'INSTALLATION REPAIR/ADDITIONJJ"(No septic tank or seepage pit permitted if public sewer is �� _. g, =+-F -• > available within 200 feet.) 1i (� Installation will serve:07A Residence commercial _ Other / ~ Number of living units o,_�'Number of bedrooms J Lot size Character ofasoil todepth of 3 feet: - Water table depth4 -S ,.e SEPTIC TANK :1 Type/Mfg fdl�' S Capacity}�o7Q�w No. Compartments M, TREATMENT PLT.-E] � Type/Mfg *. Capacity "►. Method of Disposal li Distance to"nearest: Well --� Foundation ZQ _-0 Line Line ) LEACHING LINE ' No. & Cehgth of lines '3-- f AJI Total length/size FILTER BED �i Distance to nearest:, Well Foundation Property Line R SEEPAGE PITS E]JE Depth � .: y�,�5ize 'v +. Number SUMPS F-1Distanceto nearest: Well Foundation-b- Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application an&-that the work,will be donelin accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health,District. 1 1 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." 1 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, V shall employ.persons subject to workman's compensation laws of California." The applica t ca for motions. Complete drawing on reverse side. ( j �_ �� _ Signed N Titlei:vt\ 'Date: OR P=E ONLY i Application AccepFted by Area Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date [� Manteca 823-7104 Final Inspection 1by Date Tracy 835-6385 ' Applicant - Return all copies to: Environmental Health Permit/Services 1601,.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 er FEE`' -BASE AMOUNT.°,DUE .t AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 12 7 r 4 EH 13-24 REV'-10/82 14-26 I/f//�, 4Al