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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED BATE ISSUED J (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 the San Joaquin Local eplth District.. Job Address (0 Subdivision Name Owner's Nam Address 3-7 '�, Phon g Contractor's Na License No. Phone, _S Q�- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 PackTrac ❑ Y Dia, of Well Casing ❑ Public ❑ Other [] bel to L_# IrrigationType of Casing Approx. � Eastern ❑Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done EJType of Pump H.P, State Work Done r„ Well Destruction E] Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION P�r (No septic tank or seepage pit permitted if public sewer is _Z Installation will serve: Residence _v Commercial Other available within 200 feet.) Number of� living us: . _ Number of bedrooms nitLot size �7 (`�,(ylJ�, Character of soil to a depth of 3 feet: Water table depth Q SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal arff Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines �-f_ undation Total length/size -- ' FILTER BED ❑ Distance to nearest: Wel Property Li _ SEEPAGE PITS Cj 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 applicant us call for all required inspections. Complete drawingoneverse side. Signed X Title: 11// Date: , FOR DEPARTMENT USE ONLY � f Application Accepted by Area " r Stk 466-6781 Additional Comments: ' Lodi 364-3621 Pit or Grout Inspection "`� Date Manteca 823-7621 Final Inspection by 04 Date ❑ Tracy 835-6385 Applicant - Return all copi s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT N0. oJ_ EH 13,24 REV. 10/82 14-26 10/82 500