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1 I APPLICATION FOR PERMIT , SAN JOAQULN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUEO �C_ -J,, JRAJ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) r 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 Joaquin Ubcal Health District. Job Address ,. Subdivision� Name-- [�.f� .q > Owner's Name Address i Phone Contractor's Name License No.,. / Phone i� � I TYPE OF WELL/PUMP WORK: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR j OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial ❑ Open 'Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑0ther ❑ Delta Type of Casing I ❑ Irrigation Approx. ❑ Eastern i Depth Specifications w ' Cathodic Protection .# Depthaof Grout-Seal--r�..,:_: I—] Geophysicalo s Type of Grout,---- LJ rout:---U Other i Surface. Seal Installed by W1 Repair Work,Done ❑ Type of Pump ' H.P. State Work Done Well Destruction U Well Diameter ` Sealing Material (top 50') _ Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION LIREPAIR/ADDITION ❑ {No septic tank or seepage pit permitted if public sewer is -n---• - - availabie-within. 200-f eet. PI Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size-, Character of soil to a depth of 3 feet: w ' " �— Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines # Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth j 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, r' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichythis permit is issued, I shall not employ any person in such manner as to become subject to workmank compensation laws of Ca-lifornia." 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 applica ust call or-al re ui ed ins) tions. Complete drawing on r7C2rroside Date- TM Signed x ,' Title: Date: TM USE ONLY Application Accepted by �w__ gy,p�bAreaj ❑ 5tk 466-6781 Additional Comments:- ❑ Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 'I Final Inspection by Date L Tracy 835-6385 Applicant - Return all copies to:. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 r - FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. V INFO EH 713-24 REV. 10/82 10/82 500 14-26