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APPLICATION FOR PERMIT r= SAN JOAQUIN LOCAL HEALTH DISTRICT 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT No. � 3 -5-7 Telephone (209) 466-6781 DATE ISSUED .3 • { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) 10 {I 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 Joaquin Local Health District. Job Address Subdivision Subdivision Name Owner's Name r.1=1- Address Phone Contractor's Name P SLS' License No, 512 Phone "-'j/ -10 r 1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F� DESTRUCTION Ej PUMP INSTALLATION SYSTEM REPAIR -'OTHER. [] ,-T- 0i DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE -1-}n FOUNDATION I AGRICULTURE WELL- OTHER WELL PITS/SUMPS '! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom E]Manteca Dia. of Well Excavation !J7 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 17 Public CJ Other, ❑ Del to IrrigationApprox. Type of Casing h Cathodic Protection g DPth ❑ Eastern Specifications Geophysical , Depth of Grout Seal U Other Type of Grout Surface Seal Installed by I Repair Work'Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter'l Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC.WORK: NEW INSTALLATION U REPAIR/ADDITION V (No septic tank or seepage pit-permitted>if=public,sewer=i \: Installation will serve: Residence�_ Commercial _ Other available within 200 feet.) Q� Number of living -units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK N Type/Mfg ,a2Z-` Capacity No. Compartments Z� C PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line .i LEACHING LINE 56 No. & Length of lines Q �fz= Total Tength/size FILTER BED° E Distance to nearest: Well Foundation Property Line SEEPAGE PITS ] Depth z-5 Size ;, Number � SUMPS lJ Distance to nearest: Well /a v` Foundation 3Z> Property Line �D X11 DISPOSAL PONDS u 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 far which this 1 permit is issued, I shall not employ:any person in such manner as to become subject to workman b 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 fo a71 requir d7ns ections. Complete drawing o verse ide. Signed X Title: _ � v. __ Date: Z FOR EPARTM NT USE ONLY1. Application Accepted©©by �'4� 'r,ZU Area / [} Stk 466-6781. Additional Comments: {7W Lodi 369-362.1 Pit or Grout Inspection by �L� ( y,,��;iy- ^ Date 1/// ❑ Manteca 823-7104't Final Inspection b y p Y ,P�,s�- Date cF ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,I�CA 95201 FEE BASE AMOUNT DUES AMOUNT REMITTED. RECEIVED BY DATE PERMIT N0. IN . a �� S7 EN EH 13.24 REV. 10/82 10/82 500 1 14-26 - r