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APPLICATION FOR.PERMIT SAN JOAQU'iN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. -9-- — -5 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 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. IB62 for well/pump rid the Rules and Regulations of the San Joaquin Localfrlealth District. Job Address A) �d�Subdivision Name Owner's Name /y /V /y1� Address OR 14 77&Dgelpl1 r/24/ /_o.,W` Phone lj 9-P0 2 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION r�r,, � PUMP INSTALLATION SYSTEM REPAIR OTHER U ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Industrial U Open Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [ Tracy Dia. of Well Casing 17 Public Other Delta Type of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal k U Other Type of Grout Surface Seal Installed by Repair Work Done E] Type of Pump H.P. State Work Done Well Destruction Vf Well Diamet r f Sealing Material (top 50') fy,/.Ef�.� Depth Jr 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 f 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 7 LEACHING LINE ❑ No. &'Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS LJ 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's 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." The applica st c 11 for all required inspections. Complete drawing on reverse side. Signed-X 40;1 �j+�(C' �sr� Title: Date: I R D ARTME SE ONLY A Application Accepted v Area f`` Stk 466-6781 Additional Comments: El Lodi 369-3621 Pit or Grout Inspection by Date L1 Manteca 823-7104 Final 'Inspection by � � Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26