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t APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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 wel3/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 3Z „t Subdivision Name -�- ! Owner's Name Dti ss Phone Contractor's Name . ' Li ense No. 3 1 Phone TYPE OF WELL/PUMP WORK: NEV�WELL ❑ WELL REPLACEMENT DESTRUCTION M 7Z7 4—rZ[g PUMP INSTALLATION SYSTEM REPAIR OTHER U / ,. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE"OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial � U Open Bottom F� Manteca Dia. of Well Excavation - U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing V w. 17-public [:] Other Delta w '+ 7, Irrigation Approx. Eastern Type of Casing W Depth Specifications F-1CathodicProtection Depth of Grout Seal `� , •, w f ❑Geophysical V U Other I yQ1Type of Grout Surface Seal Installed by Repair Work Done ?. Type of Pump V P. 1Ky Fq7 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth s Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is t 1 available within 200 feet.) Installation will serve: Residence _ Commercial _ Other { Number of living units: (Number of bedrooms Lot size Character of soil to a depth of;3 feet:- Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments F PKG. TREATMENT PET. Type/Mfgk Capacity Method of Disposal SEWAGE SYSTEM Distance`to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE u No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line MPS �L4Distance to�Barest:` Well Foundation ) Property SEEPAGE PITS � Depth"` Size""` Num y Line ! DISPOSAL PONDS f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 1 ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i 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 ust call for al requi ed inspections. Complete drawing on reverse side. Signed X Title: _ e2 Q.rli , fO `• " DEPARTME SE ONLY /a�L� P �^ .` �~ ' Application Accepted byArea [] 5t k, � G6-6781 y rns Y W 1 Additional Comments: G. ?�M odii= ":369-3b21 Pit or Grout Inspection by' Date an.teca;.823-7104 t` Final Inspection by Date L7 Tracy f.,835-6385 S;•• S Applicant - Return all copies to: Environmertal ealth Permit/Services 1601 E. Hazelton Ave., P.O. BoK.'2009, Stk. CA9 2.01 FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO;+ �l•TTI INFO EH 124 REV. 10/82 ! t 10/82 500 r 144-26