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APPLICATION FOR PERMIT 3 SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. GA '! LOCAL Telephone (209) 466-6781 DATE ISSUED HEALTH DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 02-1— 1400-- ZZ 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 nd—teT "sand Regulations of the San Joaquin ocal Health'District. Subdivision Name �071�5_KL koV_ � y Owner's Name � �p.h• Y`\0� Address S"Vv >rY1�1^ Phane�l q( — O2[ ' Contractor's Name '�'�,�.,�n.��w7Ql:\ �ri��;n� License No. 3PIi� Z— Phone' �j��"� r TYPE OF WELL/PUMP WORK: NEWWELLWELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 100 FOUNDATION AGRICULTURE WELL OTHER WELL / PITS/SUMPS �- +` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F t7 i IJ Industrial Open Bottom Manteca _ Dia. of Well Excavation 'Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing L7 Public 71Other Delta Type of Casing V Irrigation Approx. E]Eastern Specifications Cathodic Protection Depth Depth of Grout Seal . r Geophysical Type of Grout Other' U 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 501) I TYPE OF-SEPREPALRJAIIDIT_ION�U_-(No,.septic,tank or seepage pit permitted if public sewer is available within '206 feet.) Installation will serve: Residence _ Commercial _ Other i Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK x, f7j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal 4 j SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line i DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size „FILTER BED Distance to nearest: Well Foundation Property Line yr+` SEEPAGE PITS Depth ; Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �I 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.- 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 shall employ persons subject to workman's compensation laws of California." The applicant uyt 1 for 11 re inspections. Complete drawing on reverse side. C. Signed X . Title: Date: FOR DEPART NT USE 4?� 5tk 466-67$1 Application Accepted b Area Additional Comments: l .Lodi 369-3621 Pit or Grout Inspection by Date 7T Manteca 823-7104 Final Inspection by Date / Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/5ervices 1601 E. Hazelton Av 0. Box 2009, St k., CR 95201 FEE BASE AMOUNT DUE - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. .. f INFO 10/82 506 EH 13-24 REV. 10/82 14-26