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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3_J q Telephone (209) 466-6781 c DATE ISSUED � �O PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ' i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein j 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 apTyegulations of the San Joaquin Lonca� Health District. .tet r Job Address � — CUA&o ri4! ' Subdivision Nae Lao E Owner's Name Q 4A_1SCW_ Address jT -- Phone Contractor's Name License No. 2 0 Phone ) TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION �f W PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE r„ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Vv INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack Tracy Oia. of Well Casing Public [I Other Delta Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth El Cathodic Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by r� Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') ? I TYPE OF SEPTIC'WORK: NEW INSTALLATION REPAIR/,ADDITION ❑ (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: I Number of bedrooms 21 Lot size _ ! Character of j _ soil to a depth of 3 feet: Water table depth p� 5 SEPTIC TANK Er-�Type/Mfg Capacity 71,710 No. Compartments r� PKG. TREATMENT PLT. ',,,Type/Mfg w Capacity Method of Disposal SEWAGE SYSTEM Oi'stance to nearest: Well r Foundation [ Property Line DESTRUCTION LEACHING LINE Fy_No. & Length of lines �Total length/size �P FILTER BED Distance to nearest: Well Foundation _t Property Line �(} SEEPAGE PITS Depth Size Number j SUMPS L Distance to nearest: r Well -Foundation- Property Line DISPOSAL PONDS ❑ . I hereby certify that I have prepbr.e& Hs 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 workmant 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 ploy ersons subject to workman's compensation laws of California." The applic t u ca for a u' ed_ inspections. Complete drawing on reverse side. Signed K Title: ,(A, Date: FOR DEPARTMENT USE 0 LY ❑ Application Accepted by Area„ �-�_ Stk 466-6781 Additional Comments: i Lodi 369-3621 Pit or Grout Inspection by Date, Manteca 823-7104 Final Inspection by Date _7i _ ❑ Tracy 835-6385 Applicant - Return all copies o: . Environment��,�,t�/Slrvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT R€MITTED RECEIVED BY (DATE aq PERMIT N0. INFO 10/82 500 EH 13-24 REV. 10/82 14-26