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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Lf 1501 E. HAZELTON AVE., STOCKTON, CA \ PERMIT NO. '?L -SS 3 Telephone (209) 466-6781 VL J DATE ISSUED r7 7'-g� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / (Complete in Triplicate) Application is hereby made to the San 3oaquin 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 Joaqu'n Local Health District. Job Address 3 nd Subdivision Name Owner's Name ° Addre�s.Vy3/`,3. 7L d&�f&o Phone Contractor's Name License No. .i2 a 2_2,Z ., Phone OS" TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom []Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Irrigation Type of Casing ug Depth ❑ Eastern Specifications [:]Cathodic Protection Depth of Grout Seal ❑Geophysical ] U Other Type of Grout A Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done f^ Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 7N Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION P TION D (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 3.- - Lot size / Q Character of soil to a depth of 3 feet: y f_y Water table depth 9D SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - Type/Mfg Capacity" Method of Disposal SEWAGE SYSTEM 11---� Distance ta.nearest:.. We11___ Foundation - Property-'LineDESTRUCTION LEACHING LINE No. & Length. of lines-/ - p '" "Tdt I Ieng'th/size 41�7/_��- FILTER BED ❑ Distance to nearest: Well —�� Foundation -.Property Line - SEEPAGE PITS Depth J Size Number SUMPS Distance to nearest: Well Property Line - - — DISPOSAL. PONDS ❑ I hereby certify that I have prepared this application%and_-£hat the work will be done in accordance with San Joaquin county ordinances,. state laws,.-and_rules,and„regula.tions.-or-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 A's issued, I shall employ persons subject to workman's compensation laws of California." .r-.- ....��rr The applicant st+cal h or 11 required inspections. Complete drawin reverse side. C� Signed X Title: VIP Dater F EPARTMENT USE ON on Applic Accept by Area ❑ Stk 466-6781 Additional Comments: -- Lodi 369-3621 P�r Grout Inspection by Date g,V ❑ Manteca 823-7104 Final Inspection by DateTracy 835-6385 Applicant - Return all copie to: Environmental alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REITTED MRECEIVED BY DATE PERMIT NO. INFD ff5 +5 EH 13;24 REV.- 10/82 I0192 500 14-26