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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. i Telephone (209) 466-6781. ( _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a Permitto construct and/or install the work herein r 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 RegulationAl-of t San-Joaquin Lo 1' ealth District. � Job Address � /VE � Subdivision Name Owner's Name Address �. Contractor's Name Phone seNo. .r _ Phon� 1 TYPE OF WELL/PUMP WORK: NEW WELL _ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE.TO NEAREST: SEPTIC TANK f SEWER LINES / / / { ` DISPOSAL FLD. ' * PROP. LINE ' iI ' FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS ,^,,, INTENDED USE ��f " _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dustriai pen Bottom rn Manteca �'�"` amu❑ Y Dia:jof Well Excavation mestia/Private - --D.Gravel..Pack_._,.,. _.,Trac. r` JI Public ❑ y ' - -- — Aa•"'0f_Well_'Cas.ing. CJ Othef El Delta Irrigation Type of Casing Approx. ❑Eastern LY ❑Cathodic Protection Depth Specifications �� G " ' ❑Geophysical Depth of Grout Seal ;4 ❑Other Type of Grout r Surface Seal Installed by Repair Work Done ❑ T e of Pump H p ,-, State W Done Z -Well Destruction WelI Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ' r� TYPE OF SEPTIC WORK: NEW TNSTALLATIDN ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of livingunits : Number of bedrooms Lot size i Character of soil0to-a:depthof a3 feet: ;lt I f � Water table depth SEPTIC TANK " ❑ E Type/Mfg a-u 1 PKG. TREATMENT PL-(.1 S. ` Capacity No. Compartments ¢ ❑ Type/Mfg. Capacity Method of Disposal 3[�.✓" SEWAGE SYSTEM g Distance to nearest: Well DESTRUCTION � � I Foundation ;s ". Property,Line_, " LEACHING LINE p s❑ No: b Length of lines Total,.length/size FILTER BED E ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE.PITSL ❑ epAh 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 became subject to workman compensation laws of California." Contractor's hiring or sub-contrac g signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall m y persons subject to workman's compensation laws of California." Signed X The app7i n st all or al quire inspgctions. Complete d ing o reverse side, k r Title: o Date r'/`f-` F DEPARTM T USE NLY / � t Ap i cation Accepted by� Area f A❑ Stk 466-6781 Ad itional Comments: Pit or Grout Inspection by Lodi 369-3621 Datef C,6 Manteca 823-7104 G Final Inspection by Date /Vo Tracy 835-6385 Applicant - Return all copies to: Environments Health Permit/Services 1601 E. Hazelton Ay , P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 / 14-26 10/82 500