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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q 31-3 3 1601 E. HAZELT04 AVE., STOCKTON, CA PERMIT NO. 3 J+ . Telephone (209) 466-6781 GATE ISSUED 7 PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED (Complete in Triplicate) App ication,is hereby made to the San Joaquin Local-Health District for a pernit'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 nth/e San Joaquin Local Health District. !g Job Address Subdlvision.Name Owner's Name G—.Ad- Address "a 14,J Phone Contractor's Name �>fBaea(/ �Alu..>!��/ License No. /43 — �1�-- Phone �l lfpl— 'Ib7.b _A e W TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION + . - PUMP INSTALLATION 6f1 SYSTEM REPAIR ❑ OTHER ❑ 1 —DISTANCE TO NEAREST: SEPTIC TANK." Ir SEWER LINES DISPOSAL FLO. PROP. LINE (1-) FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ �l'J,``• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing j ❑Public Cl Other ❑Bel to irrigation Type of Casing — 1 l_i 9 Depth ❑Eastern Specifications. I Cathodic Protection Depth ❑Geophysical J Depth of Grout Seal E ❑Other - Type of Grout Surface Seal Inst Iled by Repair Work Done Type of Pump H.P, ; (AD State Work Donea Well Destruction ❑ Well Diameter Sealing Material (top SO') = _ Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONOS Lj 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, 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 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 call for all required inspections. Complete dr rin on Eeverse e. .Signed X �/7'af/ Titl - iI �eS Date: /,/ (� DEPARTMENT US ON Application Accepted by 7y • � yo,.,�_� Area o� ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 i Pit or Grout Inspection by Date ] Manteca 823-7104 Final Inspection by Date 3 ❑ Tracy 835-6385 Applicant - Return all copies to. Env anmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT CUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10182 500 14-26 I