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APPLICATION FOR PER'17 ' SAN JOAQLiN LOCAL, HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, W-3 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 and the Rules and Regulations of the San Joaquin Local Health District. Job Address 911-7 . 0,0,44E-L. -0d. _r1ZA4y Subdivision Name C)i Owner's Name Address Phone � �1Q Contractor's Name License No. Phone*.). l- G `TYPE Of WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t 1J Industrial U Open Bottom F-j Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack ]Tracy Dia. of Well Casing } ' k D Public F-1 Other [l Delta Type of Casing LjIrrigation Approx. Eastern Depth Specifications Cathodic Protection � Depth of Grout Seal Geophysical "• U Other K Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done 1 Well Destruction LJ Well Diameter � Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ste' (No septic tank or seepage pit permitted if public sewer is t1 4 available within 200 feet.) m r Installation will serve: Residence X_ Commercial :!'Other Number of living units: Number,of bedrooms Z Lot size Character of soil to a.depth of 3 feet: '_< Water table depth fQ G SEPTIC TANK. {� Type/Mfg , ?&ggZ 1514 (f0XA!!P_ Capacity �Q_ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Lire DESTRUCTION �• 1 LEACHING LINE . I No. & Length of lines Total length/size i F FILTER BED Distance to nearest: Well 7,A�7 Foundation - ZECCI 01 Property Line SEEPAGE' PITS Cj Depth S size /�- X�-(� Number /a / SUMPS Distance to nearest: Well Foundation Property Line r !! DISPOSAL PONDS k j I�hereby certify that I have prepared this application and that the work willlbe 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-cont ractin signature certifies the following: "I certify that in the performance of the work for which this permit ' issued, I shall empl persons subject to workman's .pensation laws of California." The app, "c st call r all r fired in ections. Complete r Ing a rgverse s' Signed X Title Date: �►,,/ FOR DE RTMENT USE ONLY # Application Accepted by f�a Areae" Ej 5tk 466-6781 Additional Comments: d' LV a /U� Q O C r Jas"� 17t��- ❑ Lodi 369-3621 �s Pit or Grout Inspection by Date / I Manteca 823-7104 .Final Inspection by ' _ Date � ❑ Tracy 835-6385 Applicant -.'Return a'11 copies to: '- Environm al Health Permit/Services11601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE 'AMOUNT DUE AMCUNT'REMITTED RECEIVED BY DATE- ' PERMIT NO. INFO r NO3 z{a5 d LH 13-24 REV. 10/82 10/82 500 14-26 �. R