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E APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 'Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6181 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 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 Regulati ns of the San Joaquin Local Health District. Job Address °7AfMgz� 3�dt9ision"Name ( � C,rz, Owner's Name Address Phone Z� Contractor's A. License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR a OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T ( h INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V` F-1 Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private E] Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta T Irrigation Type of Casing Li 9 Approx. Q Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done tV_] Type of Pump H.P. I State Work Done - it Well Destruction ❑ Well Diameter Sealing Material (top 50') 4 ? Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: 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 ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS El 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." f 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 applicantimust ca for all required inspections. Complete drawing everse side. Signed X ' Title: !� f Date: Application Accepted by 0 EPARTMEN U5E ONLY Area Stk 466-6781 Additional Comments: Lodi 369-3621 T Pit or Grout Inspection by Date Manteca 823-7104 final Inspection by Date 7 Tracy 835-6385 Applicant - Return all copies t 9' vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bcx 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV.e 10/823-7r'1� 10/82 5OO 14-26 �C� �E