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i 3 APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S-3----1-2110 a Telephone (2C9) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 1 � i (Complete in Triplicate) I� 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 imicompliance 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 D�ins�t,,ric��tl. _ Job Address �.ati ub0a.6psio31;;e33C� Owner's Name ,� Address 3E Phone i Contractor's Name �� License No. ¢� Phone �j ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSRL FL r PROP." LINE FOUNDATION ,; AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '�" "I JIndustrial U Open Bottom []Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing Public E]Other 1 Delta L—i irrigation Type of Casing 9 Approx. [� Eastern S ecifications Cathodic Protection Depth!j p 17 Geophysical :' . Depth of Grout Seal U Other Type of Grout f� Surface Seal Ins ailed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction U Well Diameter j Sealing Material (top 501) V Depth j Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIR/ADDITION i J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Vv Installation will serve: Residence Commerciai Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: p a Water table depth SEPTIC TANKT e Mf ❑ Yp / 9 Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION i LEACHING LINE [ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS l:1 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 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 workmant 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 applican m st all requiredliinspections. Complete wing,on reverse side. Signed X 1O-CL - Title: (I.y7'jysi{� Date: ,,IK3 DEPARTMENT Application Accepted by ,`�'f/��h,Area 7 E] Stk 466-6781 Additional Comments: # Lodi 369-3621 Pit or Grout Inspection by IV ,I Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Envir'o tal Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 � FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ; INFO -73 16Y3-td, 3 EH 13-24 REV. 10/8210/82 500 14-26 j c4kc