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u . , ``` } APPLICATION FOR PERMIT !4 SAN UOAQUitd LOCAL HEALTH DISTRICT PERMIT N0. 3 101 E. HAZELTON AVE— STOCKTON, CA .DATE ISSUED l Telephone (209) PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) hereby made to the. Joaquin Local Health District for a permit to construct and/or install'the work 'herein Application is he y ribed. This application .is made in compliance wilhSan Hea}thoDgistrictunty Ordinance No. 549 for sewage or No. 1962 for well/pump desc uin Lo G. and the-Rules nd Regulations'A the San �paq ubdivision Name Phone Job Address Address ep Phone Owner's NameLicense No. Contractor's Name WELL REPLACEMENT DESTRUCTION Y �} TYPE OF WELL/PUMP WORK: N1.EW WELL OTHER ❑ ❑ 1 PUMP INSTALLATION 'D 1 LINE T. SEPTIC TANSYSTEM REPAIR (� PROP. SEWER LINES DISPOSAL FLO. —� OTHER WELL PITS/SUMPS (�3 DISTANCE TO NEARESK=�� AGRICULTURE WELL ( ,y FOUNDATION 4 V CONSTRUCTION SPECIFICATIONS �, f INTENDE�USE TYPE_ OF WELL PROBLEM AREA , Manteca Dia. of Well Excavation industrial U Open Bottom LJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing � �Other Specifications [� Delta Type of Casing Public . Eastern irrigation ') Approx. [� Depth I)—th'of,Grout'Seal- ' '` :,.• Cathodic Protection s Geophysical � , Type of Grout U Other Surface Seal Installed by State Work Done 's Type of Pump H.P. .y.f Repair Work Done �J yP5ealin'g Mater,ial, (top.50'} Well Diameter 1 '+ Well Destruction U (Belo{ 50') Depth IFiller Material C No septic tank or seepage pit permitted if public sewer is REPAIR/,ADDITION � available within 206 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION Ll � c Commercial Other � /� ( Installation will serve: Res Lot Lot size 'l v Number of living units: Number of bedrooms Water table depth Character Of.soil•to a depth': of 3 feet: Capacity No. Compartments i SEPTIC TANK ❑ TYPe/Mfg Capacity _f— Method of Disposal PKC. TREATMENT PLT. [] Type/Mfg _ property Line. ::I Foundation _� SEWAGE SYSTEM Distance to nearest`r- Well ` 4 DESTRUCTION Total length/size � t LEACHING LINE U ' No:!& Length of lines , property Line ❑ 1 Foundation _ FILTER BED Distance to nearest: Well ` ' x Number Depth —�Y Size SEEPAGE PITS oundation SUMPS , Property Line Distance to nearest: WellF �� - y r - � DISPOSAL PONDS � r 1• hereby certify that I have prepared this application and that the work will be done inaaccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.. erformance of the work for which per in •such manner as to become subject to workman t compensation laws of California." Home owner or licensed agent':'s signature certifies the following: I certify that in the performance of the work for which this k permit is issued, I shall not employ any p ensation laws of California;;' Contractor's hiring or sub-contracting ersonsusubjectltoeworkman�slpompg I certify that in thn,p, , } this permit is issued, I shall employ p F = lican mu c l for} required , tions. Complete dra 'ng on reverse side. �iDate: (J The app # Title: Signed X OR DEPARTMENT USE ONLY 5tk 466-6781 Application Rccepted1by � � Area Lodi 369-3621, Additional Comments: ❑ateManteca 823-7104 .�, ,, D ' Pit or Grout Inspection by L7 Tracy B35-6385` •' ` � Date '�� _ ~..._ Final Inspection by P.O. Box 2009, Stk. CA 9` Applicant - Return all copies to: Environmental Health Permit/Services 1601 f. Hazelton Ave., PERMIT N0. RECEIVED BY' DATE FEE BASE AMOUNT DUE AMOUNT REMITTED INFO �Q- a� l� v� !J 3^ I; 7 10/g2 500 EH 13-24 REV. 10/82 c 14-26 J r' _