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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT OIC 2 n! 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 - iJ- Yiri tvF'� 3 pi?u �� Sc,':!?n SERVICE Telephone (209) 466-6781 PATE ISSUED SIE:lkan, C i f. 97205 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i�+�• 'i0J-�?GL Cont`-.-c vr'S E_Ic...??6717J (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 and the Rules and Regulations of t San JoaquinL cal Health District. Job Address ubdivision Name Owner's Name Address �y� Phone u Contractor's Name icense No. a2 / Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �.N 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 ❑ Public ❑ Other ❑ Delta Type of Casing F-1 Irrigation Approx. [] Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') a� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑� REPAIR/ADDITION (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: Num er of bedr/IW ,�._ Lot size F Character of soil to a depth of 3 feet: .CLD'7++ _ Water table depth , SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Wel Foundation Aa— Property Line S77 DESTRUCTION LEACHING LINE No. & Length of lines Total length/size er f FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` SEEPAGE P1T5Depth Size Number f SUMPS ❑ . Distance to nearest: Well / oundation ,___ Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 agenf's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 ceftifies the following: "I certify that in the performance of the work for which this permit is issued, h�shall,employ persons subject to workman's compensation laws of California." The applicant t 1 for all required inspect' ns. Complete drawing on rse side. Signed X Title: Date: DEP TMENT ONLY Application Accepted b Area Q ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by DateWFH,z'.l't.n 9 ❑ Manteca 823-7104 Final Inspection by i Date7 A L7 Tracy 835-6385 Applicant - Return all copies to:_Fnvironmental Health Permit/Services 1601 Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOJNT REMITTED RECEIVED BY DATE PERMIT NO. INFO411 U _ [� EH 13-24 REV. 10/82 ce {10/82 500 14-26 Pu ..+c t,4}1� Z �b hnUT a� ;c.li7ce- -C).