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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, 3 ��Qa ! Telephone (209) 466-6781 i DATE ISSUED —Z-•r3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in.Triplicate),':" I Application is hereby made to the San Joaquin.Local Health Di strict 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 SII . Subdivision Name _ J� Owner's Name '7�:� Address S"' / phone Contractor's Name License No. Phone ill. y ,h F TYPE OF WELL/PUMP WORK: 1I' NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ 4 PUMP INSTALLATION SYSTEM REPAIR OTHER f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IM 4 INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t ❑ Industrial I "❑ Open Bottom ❑ Manteca Dia. of Well Excavation k ` Domestic/Private i Gravel Pack ❑ Tracy Dia, of Well Casing 17 Public Other Delta i Type of Casing 71 Irrigation Approx. ❑ Eastern y i ❑Cathodic Protection Depth Specifications r Geophysical 4 . Depth of Grout Seal 1 ❑Other Type of Grout t ,�-.f Surface Seal Installed by ry�. Repair Work Done!Typei�f Pump N.P. State Work Done Well Destruction U We11�Diameter Sealing Mate ial (top 50') Depth. Filler Material (Below 50') 9M 9 TYPE OF SEPTIC WORK: NEW:'INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 2.00 feet.) �l Installation will serve:I Residence _ Commercial Other i Number of living units: � Number of bedrooms � Lot size pJ Character of soil to a depth of 3 feet: i.P Water table depth SEPTIC TANK ❑ -Type/Mfg Capacity No. Compartments IM PKG. TREATMENT PET. Type/Mfg Capacity Method of Disposal ❑ IM SEWAGE SYSTEM ".Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ 'No, & Length of lines Total length/size 1M \ FILTER BED distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number aR II SUMPS ❑ 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 i 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 st call for all requ'red inspections. Complete drawi g on reverse side. N Signed X d �, � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted Area [:] Stk 466-6781 Additional Commentsp pY4 Lodi 369-3621 Pit or Grout Inspection by Erate El anteca 823-7104 Final Inspection by11! Date L7 Tracy 835-6385 Applicant - Return all copies t6 Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,1M CA 95201 Jl� �I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.::I�' INFO L---- rr � �I I! EH 13-24 REV. 10/82 / �® ^ 10/82 500 Y 14-26