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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA +�b Telephone (209) 466-6781 PERMIT NO. _ � 4 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 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 and the Rules and Regulation of the San Joaquin Loc 1 Health District. /pump Job Addres ' Subdivision ,Name � Owner's Name Address ��`�� /� l/✓_p � Contractor's Name Phone License No. �� Phone 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP$ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial" ❑Open BottomManteca ❑ Dia. of Well Dometic/Pivate Gravel Pack Trac Excavation W ❑ sr ❑ ❑ Public ?' ❑ y Dia• of Well Casing __1 ❑ Other ❑ Delta Lj irrigation Type of Casing 00 Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications ❑ Geophysical Depth of Grout Seal I U Other ,. Type of Grout Surface Sea•1 Installed-`by- Repair Work Done ❑ Type of Pump H.P. State Work Done ` Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) C TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is Y` Installation will serve: Residencet" Commercial Other ,�_ ..available within 200 feet.) _ _ Number of living units: ! Number of bedrooms ��r , �.._ Lot size - i Character of soil to a depth-of-3:feet: --_ _ _Water_table depth gam SEPTIC TANK ❑ Type/,Mfg Y. _ Capacity No. Compartments + PKG. TREATMENT PItiT.,❑ Type/Mfg__ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well. Foundation h DESTRUCTION ❑ Property Lina LEACHING LINE !/ No. & Length of Tines Total length/size FILTER BED ❑ Distance to nearest; Well Foundation !O Property Line 5' SEEPAGE PITS EI Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I' 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 i permit is issued, I shall not employ any person in such manner as to become subject to workman compensation Taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the wo k for which this permit is issued I shall employ persons subject to workman's compensation laws of California," The applica must 1 r all required inspections. Complete drawi on reverse side. Signed X �� Title: ' � Date: R D TMENT SE ONLY 4a Y.!�_ App at16n Accepted by Area e LD Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ~� ❑ Manteca 823-7104 Final Inspection by Date 601 Applicant - Return all copies to; . Envir ental Health Permit/Services 1 ❑ Tracy 835-6385 . Haze ton Ave., P.O. 3ox 2009, Stk., CA 95201 j FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO EH 13-24 REV. 10/82 14-26 I0/82 504 i