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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 (]-L-/ Su iivvisior Name Owner's Name (�ljr7�S Address /—, o. f' Phone 23 Contractor's Name Sejr= License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Vim, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h Industrial r ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Privarte ❑Gravel Pack []Tracy Dia. of Well Casing ❑ Public ❑ 0ther E] Del ta V ' Type of Casing 71 Irrigation Approx. Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal;Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top 50') _ -- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is r h available within 200 feet.) V I -,_Installation will serve: Residence _ Commercial Other j Number of living units: —��.__ Number of bedrooms Lot size Character of soil to a depth of 3 feet: Sd Yl G/ Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments v 1 p PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well � Fourdat-ion—l:�-,', —.property,.L..ine--_. DESTRUCTION ❑ LEACHING.LINE No. & Length of lines '71)X- 45 Total length/size FILTER BED -, ❑ Distance to nearest: Well �j Q ! _ Foundation Property Line �{J �f SEEPAGE PITS C Depth Size *4` Number SUMPS Distance to nearest: Well r Foundatiom' Property Line DISPOSAL,PONDS r __ arrrrrr+ r.nu 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. Nome 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 sha71 not employ any person in such manner as to become subject to workmans 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 must c 11 for all required inspections. Complete drawing on reverse side. • Signed X Title: Date: R DEP MENT USE ONLY Application Accepted by �im Area ❑ 5tk 466-6781` Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823=7104 Fina9 Inspection by - Date. —T-racy . 835-6385��„f - Applicant - Return all copies tc:. E ' nmental Health Permit/Servic`es 1.601 E. Hazeltdm-Ave., P.Q. Box 2009, St k., CA 95201 l ----"FEE"' 'SASE— AMOUNT DUE - AMOUNT REMITTED.- -- ,.RECEIVED._BY.- --DATE PERMIT NO.- .-. ., INFO � rJ� LS._Y t M-/8250; f EH 14-26 REV. 10/82 (1 I