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APPLICATION FOR PERMIT *00 SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3 - �� Z L Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 and the Rules and Regulations of the San /J,l0 quin Local Health District. Job Address 466-721 la//4 'S .rcY, 5 Subdivision Name L -3F e�7 Owner's Name J✓ �/2,/ Address J/yy?C Phonefly Contractor's Name A.�P./S pA)5 License No. Phone r TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� Industrial ❑ Open Bottom Manteca Dia. of Well Excavation LLI Domestic/Private Gravel Pack Tracy Dia. of Well Casing (] Public �j Other Delta T ypeIrrigation pec of Casing L� 9 Approx. �Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal L. ❑Geophysical ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 6' Well Destruction ❑ Well Diameter Sealing Material (top 50') rr Depth Filler Material (Below 50') 1 LTYPE OF SEPTIC WORK: NEW INSTALLATION (—I REPAIR/ADDITION g(No septic tank or seepage pit permitted if public sewer is J available within 200 feet.) Installation will serve: Residence X Commercial Other L Number of living units: �- Number of bedrooms � Lot size Character of soil to a depth of 3 feet: iyoy/fyg;fr Water table depth S i SEPTIC TANK .5-e Type/Mfg �ljg/c --ps}P?is Capacity /;9_,90' No. Compartments 7— PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well �O. Foundation ��/' Property Line L DESTRUCTION ❑ LEACHING LINE Lf No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS ❑ Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ V 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 workman5 compensation laws of California." 111 Contractor's hi ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i s ed, I shall employ rsons jecyy to workman's compensation laws of California." The appli a I fo 11 re ed ' p tions! Compl r g on reverse side. / Signed K tl e: A Date: Q— `' L \' R1 \ ONLY 466-6781Appl Application Accepted by `� AreaStk Additional Comments: / Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by / Date/0 m-S 3 L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT NO. INFO �$ yS� °� - In a1 �3_ �3-lady EH 13-24 REV. 10/82 10/82 500 14-26