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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J�a-3-)L S Telephone (209) 466-6781 DATE ISSUED I A —3 "+$'; PERMIT EXPIRES 1 YEAR FROM GATE 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 C and the Rules and Regulations of)the San Joaquin Local HHeeallmth D�isttri Job Address /.746/1 OV, .�t� ,,•t��S4tTd iv l's�i ` Owner's Name ddress 1,0,6 144&&.� .uL�,.,/ Phoner 4-7—/& T Contractor's Name License No. �s�� Phone L TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 6. PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE LFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia.' of Well Excavation ❑ Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing L. ❑Public [j Other ❑Delta Tp ee of Lasing LJ Irrigation Approx. Eastern ❑Cathodic Protection Depth Specifications ✓ Depth of Grout Seal ❑Geophysical - r Other Type of Grout f-1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done 6. Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U 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: Jd/kY/k[/ Water table depth /00 f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal G SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line r-1- DESTRUCTION ❑ LEACHING LINE No. 8 Length of lines Total length/size !!ll,�� FILTER BED ❑ Distance to nearest: Well /OOH Foundation �! r Property Line /{7 - ` SEEPAGE PITS Depth Size /1 V Number SUMPS Distance to nearest: Well Foundation 60 Property Line /O 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 per•fo nuance of the work for which this 0__ permitis issued, I shall not employ any person in such manner as to become subject to workmank compensation laws of California." Contractor's h' ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall emplo pers subject to workman's compensation laws of California." The appli t call f all r red ns ctio Comple�e�iy n reverse side. Signed X Title: Date: L. TMENT ONLY Application Accepted Area ❑ Stk 466-6781 Additional Comments: r Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ' ❑ Tracy 835-6385 r Applicant - Return all copi4s to: Environmental Hea h Permit/Sertvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO O c� a1 L EH 13-24 REV. 10/82 ^f 10/82 500 14-26