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W APPLICATION FOR PERMIT / J SAN JOAQL'iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA f �/ PERMIT NO. Telephone (209) 466-6781 r �— (� .� C� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED O ti (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 Health District. Job Address 7 Subdivision Name _ l Owner's Name Address S /V Phone Contractor's Name 0 ;tR License No. Phone qq - (u 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 a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industri"al ❑ Open Bottom 0 Manteca Dia, of Well Excavation 71 Domestic/Private ❑Gravel Pack []Tracy -+ - ;'vDia. of-Well Casing 1 Public °' ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal e ❑Geophysical Type of Grout ❑Other a Surface Seal Installed by Repair Work Done ❑ Type of Pump is H.P. State Work Done v Well Destruction'❑` well 'Diameter Sea Ling Material (top 501) 3 R Depth Filler Material (Below 50`.) ,TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) s Installation will 'terve: Residence i/ Commercial _ Other � Number cf�living units: 11,L Number of b6de oins 3_ _ Lot size Character�bf soil to a"depth of 3 feet: CM �} Water table depth �. SEPTIC TANKS ❑ Type/Mfg CQNC' : @ ^^ CapacityAw _ _ No. Compartments (~ PKG. TREATMENT PLT. ❑ type/Mfg + } Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation /d Property Line / DESTRUCTION LEACHING LINE {I, No. & Length'of lines 4 O r jE r4) Total length/size FILTER BED t ❑ Distance to nearest: Well /O d " Foundation f0 Property Line SEEPAGE PITS Depth Size _3(, Number l Foundation 0 Property Line SUMPS ❑� Distance to nearest: well /_0 OO r � • DISPOSAL PONDS ❑� { 3 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 wcrkmin's compensation laws of California." The applicant-must call f r-all required inspections. Complete drawing on reverse side. Signed ( r`N Title: _ R Date: + �� F R FPARTMENT US ONLY Application Accepted by :Area 4� ❑ Stk 466-6781 i Additional Comments: Lodi 369-3621 �r Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by - --Date -•Tracy-__-835-6385.. - .:y Applicant - Return all copies to: Environmertal alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RFCEI-VED BY DATE. r ..!PERMIT NO. f INFO ___10182-500 _10/82.,500, - EH 13-24 REV. 10/82 14-26