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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL, HEALTH DISTRICT p 1601 E. HAZELTON AVE-, STOCKTON, CA PERh1IT NO. a 3 Telephone (209) 466-6781 L4-Z + DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) M k Application is hereby made to the San Joaquin Local Health District four- a,:permit to construct and/.or install the work herein f` described. This application is made in compliance with San Joaguin`Lounty Ordinance No. 549 for sewage or No. 1862 for'well/pump and the Rules and Reg lations of the San Joaq in Local Health District. �. Job Address Subdivision..Name Owner's Name Address L)k S Phone k Contractor's Name L �CC- License No, t Phone. 31� # TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP I_NS-TAL`LAT16 ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:-SEPTIC NK SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom ❑ Manteca ti Qia. of Well Excavation ❑ 0omestic/Private Gravel Pack ❑ Tracy Dia'"of-Well+Casing.e— ❑ Public other- lt 4 Del f❑ ❑ Type of Casing � [jqrrigation Approx. [] Eastern Specifications i Cathodic Protection Qepth LL , Depth of Grout Seal 17 Geophysical I Type of Grout Oter $ Uh � 1. d Surface Sealnhnstal-led by n n �.. - Repair Work Done F] Type of Pump H.P. State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501) ' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION ❑;(No septic tank or seepage,pit permitted if public sewer is .% j i available within 200 feet.) Installation will serve: Residence Commercial Other i Lot size 1 f �lh t V Number of living units: �_ Number of bedrooms � i `d�X �w Water table depth Character of soil to a depth of 3yfeet: L.� 1ST+ ,r-� SEPTIC TANK Type/Mfg V Z Capacity (�U No. Compartments d- PKG. TREATMENt PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION i ° LEACHING LINE I� Na. & Length of lines - Total length/size' 0. FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS � Depth t SizFe �� Number ( Distance to nearest: Well Foundation t Property Line SUMPS I r! 1t DISPOSAL PONDS ❑ 1 # hI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county 4 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 thisperm' issued, [ shall employ persons subject to workman's compensation laws of California." The app] cat us 11 llgUired inspections. Complete drawing on reverse side. r Title: �C-� �� t Date: Signed x { i R Q RTMENT USE ONLY f Application Accepted by Area &* ! 3 _ �Stk 466-b781 d t ❑ Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date ❑ Manteca 823-7104 Firal Inspection by f Date /��l ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE k. . FEE BASE AMOUN�T/DUE RMOUNT REMITTED RECEIVED BY ( QATE (]PERMIT N0. 3 - r) 10/82 500 EH 13-24 RLU. 10/82 p� elk"-e-c- 14-26 eG14-26