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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �Q 2 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 S 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 Joaquin Local Health District. Job Address yC-3 Subdivision Name -5, Owner's Name .EG , 45eq y C- �`�9 Address 34j OQIp 1-4HSt0/r V Phone k3 6 .7 1/5-4' Contractor's Name i .�'9/,VLicense No. 46 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ W PUMP INSTALLATION SYSTEM REPAIR OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (} INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FlIndustrial U Open Bottom []Manteca Dia. of Well Excavation Domestic/Private r_J Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public CJ Other EJ Delta Type of Casing LJ Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal 0 Geophysical Other Type of Grout L Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') TIN Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION Jyf (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence .a' Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size .140 jr /0,0 Character of soil to a depth of 3 feet: Water table depth ip SEPTIC TANK KC Type/Mfg Chs T Capacity d o V c. No. Compartments 2, PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation /4i Property Line S SEEPAGE PITS Depth Size 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 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 mus all for all required inspections. Complete drawing on reverse side. Signed X ! �a G Title: Date: /10-83 FOR PARTMENT USE ONLY Application Accepted by . G Area Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by l C�`7. Date /?-8`3 Tracy 835-6385 Applicant - Return all copies to: Environm al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Ing 11S EH 13-24 REV. 10/82 10/82 500 14-26