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APPLICATION FOR PERMIT 4 .SAN JOAQUiN LOCAL HEALTH DISTRICT S3-B,?5'CV -1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. f1,nwa4 Telephone (209) 466-6781 DATE ISSUED IZ-1"3 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 compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump i and the Rules and Regulations of the San Joaquin L cal Health District. c� Job Address Subdivision Name Owner's NameAddress 9 ..:y Phone -/-� 3 /� c) Contractor's Name I License No. a267_4 Q/ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION CJ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK sad SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS JV Industrial [] Open Bottom 7 Manteca Dia, of Well Excavation �j Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing `❑ Public [—I Other Delta Type of Casing Lj Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal () Q� I—]Geophysical Type of Grout 4Z%e" s �7 Other Surface Seal Installed by Ptzsr*/] Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Lf Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other rryye� Number of living units: Number of bedrooms Lot size ( pl 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 ?' I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line Q- DESTRUCTION LEACHING LINE jJ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number Q. 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 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 cal for r quired inspections. Complete drawing on reverse side. �- Signed X_ =,� s� ilf �Y� Title: S Date: Z� FQh DEPARTMENT USE ONLY ? Application Accepted by Area J Stk 466-6781 Additional Comments: E] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copi s Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �� T-_I� _g) g3- FSS e11 !�fi l( Vs �7 i�r"4P EH 13-24 REV. 10/82 10/82 500 14-26