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APPLICATION FDR PERMIT . SAN JOAQUiN LOCAL HEALTH DISTRICT �p f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a 3 — q S 1 k� 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 Joaquin Local Health District, fi Job Address 4{ �D _ Subdivision Name Owner's Name Address a - Phone G Contractor's Name A- License No. Phone ^^�� A TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' DISTANCE TO NEAREST: -SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION {sl AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ~ Domestic/Private ❑ Graved Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta 11 Type of Casing Irrigation Approx. E]-Eastern Depth Specifications ❑Cathodic Protection p ❑Geophysical Depth of Grout Seal Type of Grout Other E Surface Seal Installed by 1 F Repair Work Done ❑ Type of Pump ; H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material .(top 50') Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) f P1 Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms J_�2 Lot size �'C 4-c . Character of soil to a deph of 3:feet: :Water table depth SEPTIC TANK ❑ Type/Mfg Capacity (1-_60 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg 'f Capacity Method of Disposal ' SEWAGE SYSTEMr ' Distance to nearest: Well �� Foundation Property Line i DESTRUCTION ❑ LEACHING LINE ✓ No. & Length of lines _ P: Total length/size ` ""_1 ar� FILTER BED Xr Distance to nearest: Well Q. Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ r 77)l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county �F 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 followings 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." P The applicant must call for all re spettions. Complete drawing on reverse side, y~� Signed X 4 Title: Date: D TMENT USE LY Application Accepted by sea �3 ❑ Stk Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date 3 ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 FEE BASE AMOUNT DUE AMOUNT .REMITTED RECEIVED BY DATE._ PERMIT N0. 6 b INFO 445 3 3-yS Currt[H`/Y �n 2 EH 13-24 REV. 10/82 10/8 500"[ 14-26 s