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APPLICATION FOR PERMIT SAH JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 33 _ 1J�7 C� r 1601 E. HAZELTON AVE., STOCKTON, CA Telephorle (209) 466-6781 DATE ISSUED / PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .(Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 Regulation of t San oaquin Local Health District. Jab AddressL !/ Subdivision Name Owner's Name Address Phone Contractor's Nam ` ' License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ O� PUMP INSTALLATION [] SYSTEM REPAIR [] OTHER E] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL DtHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA - CONSTRUCTION SPECIFICATIONS 1-1 Industrial ] Open Bottom ❑Manteca Oia. of Well Excavation Domestic/Private ❑ Gravel Pack E] Tracy Dia. of Well Casing Public E]Other Q Delta Type of Casing F1 Irrigation Approx. E] Eastern Specifications r-ICathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout Other Surface Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. State Work Done -� Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION.V REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is O ''��- available within 200 feet.) Installation will serve: Residence X!, Commercial Other Number of living units: -A1 Number of.bed ooms Lot size Character of soil to a depth of 3 et: Water table depth �(f SEPTIC TANK Type/Mfg /J- •wCapacity _ Me Compartments f�► �nz PKG. TREATMENT PLT. E] Type/Mfg Capacity _ Method of DisposLl � Distance to nearest: Well >F` Foundation - Property Line ��" 'i'- LEACHING LINE No. & Length of lines ry Total l ength/size'lx� Z FILTER BED E] Distance to nearest: Well Q-4 Foundation /0-f� Property Line^ S" +_ _ SEEPAGE PITS Depth 4C Size � Number r SUMPS LJ Distance to nearest: Well `o _ 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 applic t must ca 1 for all required inspections.' Complete drawing op rayerse side. t Signed X Title: �lJ Date: . 9J FORAEPARI_MENT USE ONLY App kation Accepted by Area Q []""Si k 66-6781 Additional Comments: Lodi 369-3621 L Pit or Grout Inspection Date [] Manteca 823-7104 Final Inspection byDate — ❑ Tracy 835-6385 Applicant - Return all copie'o: Environ n 1 Health Permit/Services 1661 E. Hazelton Ave., P.O. Box'2009,,4Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -- i 1.3 1 EH 13-24 REV. 10/82 10/B2 500 14-26