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�17> APPLICATION FOR PERMIT ! SAN JOAQLiN LOCAL HEALTH DISTRICT ( 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3— Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) µ I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein i described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump I and the Rules and Regulations of the San Joaquin Local Health District. Job Address_19 a 3 -W[L" Subdivision Name Owner's Name t�y� W Address .. � A Phone �7rf'�Z3� Contractor's Name 'fat, License No. Phone y t Z TYPE OF WELL/PUMP WORK: NEW WELLLL REPLACEMENT DESTRUCTION U W PUMP INSTALLATION ❑ SYSTEM REPAIR IED OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t dustr.ial U-Open-Bottom-= ^Q Manteca.- Dia.�of-Wel 1. Excavation -- "— U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public Other E] Delta Type of Casing 7 Irrigation Approx. Eastern Specifications ❑ Cathodic Protection Depth roecDepth of Grout Seal Geophysical 1 Type of Grout Other Surface Seal Installed by s Repair Work Done ❑ Type of Pump N.P. f State Work Done z Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other i Number of 3iving units: Number of bedrooms Lot size ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ei Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal t SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation T Property Line DISPOSAL PONDS e 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. ^„ 1 ! 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 became 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 must call for all required inspectio s. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Replication Accepted by RreaStk 466-6781 Additional Comments: ❑ Lodi 369-3621 ' Pit or Grout Inspection by Date D Manteca 823-7104 Final Inspection by Date ❑ Tracy $35-6385 Applicant - Return all copies to; Fnvir ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO l0 10/82 500 EH 13-24 REV. 10/82 14-26 ^.