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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.; STOCKTON, CA PERMIT NO. oZ 4 7 y Telephone (209) 466-6781 DATE ISSUED 11 s PERMIT EXPIRES 1 YEARIFROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the workherein described. This application is made in compliance with San Joaquin Connty-Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulesanR ulatio of the San J quin Local fie lth. District. p� Job Address ubdivision Name Owner's Name Address Phone Contractor's ame License No. Phone S TYPE OF WELL/PUMP WORK: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION [7j- PUMP PUMP INSTALLATION [] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' DISPOSAL FLD. PROP. LINE FOUNDATION 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 ❑ Public ❑Other ❑ Delta Type of Casing U irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical Type of Grout € LJ Other i Surface Seal.Installed by Repair Work Done [J- Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) 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. CommercialOther ` Number of living units: Number of bedrooms Lot size 'v Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E] Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal o6 ' Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED 17 Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well, ; Foundation 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 appli ant must 1 for"all required inspections. Complete drawing on reverse side. Signed Title: !late• FOR T9 USE ONLY 4� Applicati ccepted b Area ©� Y�fin�. ❑ Stk r 466-6781 Additional Comments: V-,, , Lodi 369-3621 Pit or Grout Inspection by Date — --� Manteca 823- 7104'Final Inspection by Date / ❑ Tracy $35-66385385 Applicant Return all copie o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITT NO. 3 INFO LAS � 7.2-67T1 EH 13-24 REV. 10/82 10/82 500 14-26