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d t A APPLICATION FCR,PE?,M -i SAN JOAQUiN LCCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, 33k Telephone (209) 466-6781 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.,Re ulations of t ;S oaq Local Health District.. Job Address Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone oZ� k TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑k 'i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (❑ 9 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOJNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation U Domestic/Private ❑,Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other• ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical '"' Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW.,INSTALLATION G:1 REPAIR/ADDITIONj J (No s ept;c tank or seepage pit permitted if public sewer is - available within 200 feet.) Installation will serve: ResidenceCommercial _ Other r} 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 ber SUMPS Distance to nearest: Well •Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will he 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 ofgthe work for which this permit is issued, I shall not employ any person in such manner aS to become subject to workmant 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 workman's compensation laws of California." i The applicant ust call for al r wired ins t o Complete drawing on reverse side. {i Signed X Title: Date: TM ENT U L 9 Application Accepted by Area Ll Stk 466-6781 Additional' Comments: ❑ Lodi 369-3621 Pit or Grout inspecti n y Y ' Date ❑ Manteca BZ3-7104 4 Final Inspection by r - .<:Date ❑ Tracy 835-6385 4 uApplicant - Return all copies to: :E V' onmental Health Permit/Servicess'',1601 E. Hazelton Ave.,. P:O._ Bax 2009, Stk., CA 95201 4 FEE BASE AMOUNT D AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1 v-r F 10182 500 EH 13-24 REV. 10/82 - 14-26 ah`,,