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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED t 1 ( r 3 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 /f/ ZZ?-tg - -sift Qr,/ Subdivision Name Owner's Name Address -..�iQy1'�_ Phone Contractor's Name }��4tLi2tl�f P .Se License No. 2-5-5/ 3 /3 Phone -Ae'-lda7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION LI 1 PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE "`- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS —" INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial (J Open Bottom Manteca Dia. of Well Excavation L7 Domestic/Private Gravel Pack Tracy Dia. of Well Casing 1-1 PublicOtherDelta L_I Irrigation Approx. ❑Eastern Type of Casing Specifications Depth Cathodic Protection .. j]Geophysical Depth of Grout Seal L7 Other Type of Grout Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lf REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is 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:,�wgyp,,e l'`,q.,-� Water table depth SEPTIC TANK Type/Mfg Capacity /X/-r0 No, Compartments �Z� PKG. TREATMENT PLT. (� Type/Mfg Capacity Method of Disposal Distance to nearest: Well A-Z` Foundation �f� Property Line Z LEACHING LINE No. 8 Length of lines - Zoo Total length/size /O cp JC Z FILTER BED Distance to nearest: Wel l,s_ : , Foundation 31-0 Property Line /b J SEEPAGE PITS ® Depth 7- 5— Size ,3 A r Number SUMPS U Distance to nearest: Well Too , Foundation 70 Property Line '1 DISPOSAL PONDS O f 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 workman5 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 mush 11 for a repot ns tions. Complete draw' o verse si Signed Title: Bate:Date: Application Accepted by PARTMENT USE ONLY Area 1-'// '�.s � Stk 466-6781 Additional Comments: L—Iff'LOdi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date -r---! Tracy 835-6385 Applicant - Return all copies to: 6vironmtal Health Permit/Services 1601 E. Hazell:n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. - EH 13-24 REV. 10/82 10/82 Soo -