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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,'CA PERMIT NO. 3 -- C&{ q Telephone (209) 466=6781 DATE ISSUED/3j Q3 I PERMIT EXPIRES _I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to f 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 and the Rules and Regulations of the.San Joaquin Local Health District, Public Job Address y3'�3 . / " " RD Subdivision Name No. & Length of lirX Approx. Owner's Name PA41FIC ACP %4#&e7— 1A,1C Address sG Depth Phone Contractor's Name Ej d YD E .1 UA" fa License No,L�+T y� 2-7L Phone. •r Type of Grout 4 Lj Other Well Foundation LS , Property Line TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U Repair Work Done -PUMP INSTALLATION SYSTEM REPAIR OTHER U We11;;Diameter DISTANCE TO NEAREST: SEPTIC TANK (top 50'.)- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE PLT. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ U Open Bottom [] Manteca Dia. of Well Excavation IJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing Public [] Other Delta Type of Casing L! Irrigation No. & Length of lirX Approx. Eastern Specifications F-1CathodicProtection Distance�to nearest: Depth t Depth of Grout Seal Geophysical Depth 'yS � E Type of Grout 4 Lj Other Well Foundation LS , Property Line tf Surface Seal Installed by 3 Repair Work Done Type of Pump '1 H.P. ' State Work Done Well Destruction.0 We11;;Diameter Sealing Material (top 50'.)- Depth Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is I 1 available within 200 feet.) Installation will serve: Residence _ Commercial ✓ Other •"—�'�� Number of living units, -�^ +umber of bedrooms � •'Lot size Q_; �S ti '`' Character of soil to aNepth of 3 feet: 1' L /;.�/'. ± Water table depth ' SEPTIC TANK Type/Mfg C_e s �.J/r - Capacity No. Compartments 1 co _Q PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal DATE PERMIT NO. SEWAGE SYSTEM ❑ Distance 'to nearest:. Well � ` Foundation -7z—_ - Property Line G DESTRUCTION LEACHING LINE No. & Length of lirX �� Total length/size FILTER BED Distance�to nearest: Well Foundati6n Property Line `) SEEPAGE PITS Depth 'yS Size r Number SUMPS U Distance}to nearest: Well Foundation LS , 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 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 must call fo all required inspections. Complete drawing on reverse side. Signed X ` r --. 'tle: Pte_ �. ,—_ --- Date:.a, FOR DEPARTMENT USE ONLY A Application Accepted. by i Area' WF R Stk 466-678 Additional Comments: 1 ❑ Lodi 369-3621 Pit or Grout Irspection by Date Manteca 823-7104 Final Inspection by ; Date= $3 ❑ Tracy 835-6385 Applicant - Return all copies to:..Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 14-26 10/82 500