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APPLICATION FOR PERMIT SAN ]OAQUi!l LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) j r Application is hereby made to the San Joaquin Local'Health District for a permit to construct and/or install the workrhe�rin 2 f 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. Job Address_+; Z'70 , SS P[ Subdivision Name Owner's Name rr µKi.. Address C44-..A_ Phone SW-6231D Contractor's Name License,No, f I b:5 A Ph`one 2 TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w i FOUNDATION AGRICULTURE WELL OTHER WELL ?I'T'S/SUMPS - 1 I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFICg3IONS Industrial ❑ Open Bottom Manteca Dia, of Well Excavation . Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public [rri non -�J Olher L] Delta Type of Casing f ii a g - ` Approx. EJ Eastern Depth Specifications ❑ Cathodic Protection P ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of-Pump- -H.P: - State-Work Done Well Destruction ❑ WeII Diameter Sealing Material (top 50') ' Depth Filler Material (Below 501) a N TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is0JI available within 200 feet.) Installation will serve: Residence )L Commercial Other Number of living units: Number of bedrooms Lot size 'C-i.{ rLQ10 d Character of soil to a depth of 3 feet: r Water table depth a Q SEPTIC TANK 91 Type/Mfg C 'Capacity /a2 O No. Compartments r PKG. TREATMENT PLT. [� Type/Mfg Capacity Ito Method'of;,DisposaI ( n 1 SEWAGE SYSTEMv 1 I Distance to nearest: Well � Foundation J 4 Property Line, DESTRUCTION ❑ i LEACHING LINE No. & Length_ of lines �.,�{ w Total length/size i {/ FILTER BED ❑ Distance•to nearest: Well (' Foundation V%O' Property Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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. { =. ,� r 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 workmanK compensation laws of California." Contractor's hiring,or sub-contracting signature certifies the following: "I certify that fn the.performance-of--the-work for which ! this permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 The applicant must call for all requir d inspections. Complete drawing on reverse side. Signed X EnkLAe, C Title,: O w c..e Date: EPARTMENT USE ONLY Application Accepted by Area le.9- (- D Stk U�2�Additional Comments: ❑ Lodi 369-e Pit or Grout Inspection by Datanteca 823-7104Final Inspection by Date 113 Tracy 835-6385Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. i INFO EH 13-24 REV. 10/82 {� �/� �. 10/82 500 14-26 v� V