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APPLICATION FOR PERMIT SAN JOAQUiA LOCAL HEALTH DISTRICT aQ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. p 3 a f Telephone (209) 466-6781 i DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) u � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install he work herein described, This application is made in compliance with San Joaquir County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations o the San Joaquin Local . lth 'strict, Job Address &division Name Owner's Name i � Address Phone r f Contractor's Nam "�'/` 'cense No. /No. / �C1 .1.� Phone 1 TYPE OF WELL/PUMP WORK: NEW WELL F_� WELL REPLACFMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE + , t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom F� Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Public Ej Other ❑ Del to Type of Casing Ll irrigation Approx. D Eastern ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _J!!!� Commercial _ Other Number of living units: _ Number of bedrooms 3 Lot size / r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 2 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well Foundation ' Property Line DESTRUCTION LEACHING LINE jam' No. & Length of linespis," Total length/size Q 2 FILTER BED ; Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth . Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will he 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 a'.1 employ e. ns subject to workman's compensation laws of California." The applic t u 'call or a h spections. Complete drawing on reverse side. Sigr Title: ��i�� Date: .- FOR DEPARTM Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by �� Date �_,1`� �-a L Tracy B35-6385 Applicant - Return all copies to: . Environmen al Health Permit/ 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY / { DATE '93 PERMIT NO. INFO 445 `�' !� ��Z EH 13-24 REV, 10/82 �j � r 10/82 500 14-26