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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �f 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. 1862 for well/pump and the Rules and Re M atiions of nth/e San Jo�qui Local H alth ract. Job Address �+ /!/- / 'dub idion Name Owner's Name Address SJ Zf2%ee Phon o7/.L 1G7� a Contractor's Name' P License No. Phone uL! TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom XVVDia. of Well Excavation U Oomestic/Private Gravel Pack Dia. of Well Casing Public � Other Irri ation Type of Casing L 9 Approx. ED EaSpecifications F—ICathodic Protection Depth Geophysical Depth of Grout Seal Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 0 (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: &l1 Number of bedweeRts (dk/ Lot size 45_?� 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 Q LEACHING LINE No. & Length of lines Total length/size d FILTER BED ❑ Distance to nearest: Wel N un an on Property Line SEEPAGE PITS Depth of Size .S, ♦1 Number / SUMPS Distance to nearest: Well /I/ Foundation Property Line J 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 compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant mu c 11 for required ins ections. Complete drawing on reverse side. 7 �� " Signed 'X' Title: Date: DESE ONLY Application Accepted by JArea Stk fi=6781 Additional Comments: 161 Lodi OF Pit or Grout Inspection by e Date /9 X-'U Manteca 823-7104 Final Inspection by Al Date 1U—/__ &3 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �sys � S. 4 o EH 13-24 REV. 10/82 10/82 500 14-26 � I� 7