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APPLICATION FOR PERMIT 3— SAN JOAQUIN LOCAL HEALTH DISTRICT 1601" E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 campliance with San Joaquin County Ordinance No. 549 for sewage or -No. 1662 for well/pump and the Rules and Regulations of he San Joaquin Local Health District. Job Address �` S J ubdivision Name Owner's Name Address - 0757/5 W a/�.E!Y�,lI_� llsAjPhone ., Contractor's Name —z License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE e '� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �N i I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ t ! IJ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑ Other [] Delta Type of Casing 71 Irrigation Approx.. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal { ❑ Geophysical Type.of Grout [J Other ~' Surface Seal Installed by 'Repair Work Done [j Type of Pump H.P. State Work Done :Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') 1 Y. S l TYPE OF SEPTIC WORK: NEW INSTALLATION L_, REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is j / available within 200 feet.) installation will serve: Residence Al Commercial Other Number of living units: Number of b d L6t size _ 5 4A:Z, p Character of soil to a depth of 3 feeQt: ,yJ6f.,,� Water table depth v� SEPTIC TANK ck, Type/Mfg Capacity' QA ( No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well 1,60//-Foundation /�7 Property Line ^rj DESTRUCTION ❑ / s LEACHING LINE LJ —No. &_Length.•of-lines- Z .y4 p�f7 Total length/size /a,!9 FILTER BEL ❑ Distance to nearest: \,Welly Foundation / Property Line J` SEEPAGE PITS [ Depth ;2L,S Size �� Number SUMPS ❑I Distance to nearest: Well /.�,i Foundation Property Line i DISPOSAL PONDS ❑ T 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 mustcallfor all. r .red inspections. Complete drawing on reverse side. // Signed X o Title: Date: !a i FOR E RTM T USE ONLY Application Accepted by� Area --- ❑ Stk 466-6781 ) Additional Comments: Lodi 369-3623 Pit or Grout Inspection by Date [J Manteca 823-7104 Final Inspection by I Date ❑ Tracy 635-6385 Applicant --Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 ,I A. FEE BASE AMOU T DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ' INFO i 10/82 500 EH 13-24 REV. 10/82 14-26