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APPLICATION FOR PERMIT SAN ,OAQU N LOCAL HEALTH DISTRICT 7 C� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 / Telephone (209) 466-6181 HATE ISSUED i PERMIT EXPIRES I YEAR FROM DATE ISSUED j (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 sof the San Joaaui Local Health District. Job Address t"LQ3 Cr fr6-ita0U ( U Subdivision Name Name Owner's Name S a!L �! 2& UZ� Addressress1 "[ hone Contractor's Name j1 7) �� , License No. �j•/1�/�Z�� _ hone TYPE OF WELL/PUMP WORK: NEW WELL ❑ LL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION STEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK f}-� SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t i Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation mestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public Fi Other ❑ Delta Type of Casing Irrigation Approx. [] Eastern ED Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by -�- Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Q Depth Filler Material (Below 50') ^� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION i❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well - Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation 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 became 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 mus l all required inspections. Complete d, on reverse side. Signed X Title: A Date: r FOR DEPARTMENT USE ONLY II Application Accepted by l.�a�Ylti Area 0/ El5tk 466-6781 Additional Comments: 1�4 Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date AIA ❑ Tracy 835-6385 Applicant - Return all copies o: Envi onmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV, 10/82 10/82 500 14-26