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APPLICATION FOR PERMIT / SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3' 4Telephone (204) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 Ordindnce No. 549 for sewage or No. 1862 for welt/pump and the Rules and Regulati of the San Joaquin Local Health District. Job Address ° Subdivision Name Owner's Name Address .� Phone Contractor's License No. _ ��-,6 Phone TYPE OF WEA LL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - []Industrial ,� ❑ Ddmestic/Private t' ❑Open Bottom Manteca Dia, of Well Excavation ❑P blit ❑Gravel Pack ❑Tracy Dia, of Well Casing �jOther Delta ❑ I rigation ` 'i Approx. ❑ EasternType of Casing - ❑Cathodic Protection ; Depth ')Specifications ❑GeopllysicaT ' ' `/ Depth of Grout Seal ❑Other Type of Grout Surface Seal.Installed by Repai ri Work Ione ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) ' Depth Filler Material (Below_SQ'),.;:`_ TYPE F SEPTIC WORK: NEW INSTALLATION 0 REPAIDD TION — No a is tank or seepage pit permitted if public sewer is ^'nom Installation will serve: .Residence _ ryc'�'. = available within 200 feet.) .-fr Commercial Other of Num�er of living units: Number of bedrooms Lot sizes O ) / T Character_lf soil-to a depth of 3 feet; C TANK Water table depth 0 0 SEPTI �f CSI Type/Mfg Q7 a Capacity 'A-0 -_1 No. Compartments PKG. 4REATMENT PLT. ❑ Type/Mfg Capacity .Method of Disposal Distance to nearest: Well O�/'-Foundation74 Property Line 3 LEACH NG LINE No'? d Length of lines FILTER BED O Total length/size ❑�• Distance to nearest: Well Foundation '•` Property Line ' SEEPA�E PITS DedthSize _IP /INumber SUMPS ❑ Distance to nearest: Well '�n�,,aaoundation DISPOSAL PONDS ❑ �� '( F Ib i�-.1.„Praperty Line Tfi^ [ her certify that I have ordinances, state laws, and- prepared this application and that the work will.be:done-in accordance with San Joaquin County rules and regulations of the San Joaquin Loca , Home Dimer or licensediagent a l HealthD.istrict. ' signature certifies the following: "I certify that*in.�the perfeTtMince of the work for which this permit is issued, I shall ��n�o__t�'employ any person in such manner as t0 become subject to,workman4 compensation laws of California." Contra tor's hiring or sublontracting signature certifies the following: "I certify that in the performance of the work for which this plemit is issued, I shall. employ persons subject,to-workmen's-compensation laws ¢f-California." ' The applicant It call for all r Signed XJ+7f9 ofired insp tions. . Complete dra n reverse side . Title: (�_�ry_. Date: --1�-,�/ �lfF �r Application Accepted by DEP USE ONLY ns Area - Additional Comments: E] Lod E] 466-6781 ! ` y Lod369-3621 Pit or Grout Inspection y Date S /7 Final Inspection by / ❑ Manteca 823-7104 Wte ❑ Tracy 835-6385 Applicant - Return all copies;to: Environmenta) Health_Permit/Services-1S E. . zelton Ave., P.D. Box 2009, Stk., CA 95201 /. tj FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. f 1N F0 S 5 `8 3-3 WkI EH 13-1REV. 10/82 14-126 — 10/82 500