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APPLICATION FOR. PERMIT SAN JOAQU.iN LOCAL HE4LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. R3 -�' 3 Telephone (209) 466-6781 y1 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//ggegula tions of the San Joaquin Local Health District. Job Address 6s�sA1 /✓1dSS DnG "' QP AM7#"Subdivision Name Owner's Name _y-146,4< /y.SThD Address ��,�^ �sjf (G RD/lli.Vs,�hone Name ACCV Contractor's V/L License No. /[S4J;$-,Z Phone _ 3 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [:J PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ G DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ) ..- FOUNDATION AGRICULTURE WELL OTHER WELL PIT5/5UMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation V' ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta Type of Casing 5 Li Irrigation Approx. Eastern Depth Specifications ❑Cathodic ProtectionDepth of Grout Seal ❑Geophysical ❑Other Type df Grout Surface Seal Installed by Repair Work Done D Type of Pump H.P. A State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') `TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is available within.200 feet.) Installation will serve: Residence X Commercial _ Other - _ '� — Number of living units: Number of bedrooms _ Lot size ---IFfwlll � J Character of soil to a depth of 3 feet: &Arxly Water table depth / SEPTIC TANK ❑ Type/Mfg 'p.,�,C♦ Capacity _ALNo. Compartments Z. 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' ��'- dj Total length/size ele1� + FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth_ Size 's` Number SUMPS U 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 workman5 compensation laws of CaTifornia." 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." //yy The applicant must cal for a required inspections. Complete drawing on reverse side. - X3 Signed %�i Title: �A�.✓tmc.t/ Date: FOR`/J/JA DEPARTMEEFSE ONLY J Application Accepted by Area Q / " C3 Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Environmental 4ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT H0. INFO 4S g�-t_ $3-Bu3 EH 13-24 REV. 10/82 `1:XI Zi/ $�3 1 1 10/82 500 14-26