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ur 7-7 APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT J Itor,AL 1601 E. HAZELTON AVE., STOCKTON, .CA PERMIT ND. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE_ISSUED - � C fete in Triplicate) af 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. 9 for sewage or No. 1862 for well/pump ; and the Rules and Regulations of the San Joaquin Local-Heal h Distri. t. I Job Address ,m ( �9bW-T idn NT S • � r r-1""' Owner's Names Address Ccs ' �-'"Phone _ (� Contractor's Name License No-. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL _OTHER-WELL_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —� Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ) s Domestic/Private ❑Gravel PackTrac ❑ Y Dia, of Well Casing ❑ Public ❑ Other ❑ Delta (J Irrigation Type of Casing e Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal c Other Type of Grout ,. #,�, Surface Seal Installed �; Repair Work Done E] Type of 'Pump _`— H.P. State Work Dane Well Destruction Well Diameter50') ❑ Sealing Material (top `J Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ` Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil 'to a depth of 3 feet: Water table depth SEPTIC TANK El Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM DESTRUCTION ❑ Oistance,tornearest: Well Foundation-., -'-;; : - -ilProperty.Line d. LEACHING LINE No. & Length of lines a Y ❑ 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number f SUMPSk ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 permit is issued, I shall not -employ an ' Y performance of the work for which this p y y person in such manner as to become subject to workman§compensation laws of California."f Contractor's h' ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ssued, I s 11 employ ersons ubject o workman's compensation laws of California." The applicant st call f 1 re u' ed in t' ns. C plete dra, ing on reverse side * 5igned X T' le: Date: OR D P ME U ONLY Application Accepted by Area ?a Stk 466-6781 Additional Comments: �L Lodi 369-3621 Pit or Grout Inspection by Dade Lodi 823-7104 Final Inspection by Date, w ❑ Tracy 835-6385 F Applicant - Return all copies to: Env me tal Health Permit/Services 160 E. H zelton Ave. P.O. Box 2009, 5t k., CA 95201 3 t- FEE INFO BASE AMOUNT 'DUE 'AMOUNT REMITTED RECEIVEb BY, DATE PERMIT NO. `S- '� EH 13-24 RFV. 10/82 } 14-26 10/82 500