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IV 11 INY 8-1 L" y LEI LUJ jUI'i � q[yp�1 APPLICATION FOR PERMIT ISI IJ 84 SAN JOAQUIN LOCAL HEALTH DISTRICT SAN JOAQUIN LMAL 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. tiMTH DISTRICT Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED to`�D - (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 a d Regulations f e San Joaquin Local Health District. Job AddressU. Subdivision Name Owner's Name a) Address 12& Phone l Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑- WELL REPLACEMENT E] DESTRUCTION F-1PUMP INSTALLATION E� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EJ_ Open Bottom ❑Manteca Dia. of Well Excavation tPio stic/Private []Gravel Pack Trac❑ y Dia. of Well Casing ❑ is ElOther E]Delta F—J Irrigation Approx. Eastern Type of Casing ❑Cathodic Protection Depth Specifications �f ❑Geophysical Depth of Grout Seal 'V ❑Other Type of Grout 6 9 Surface Seal Installed by Repair Work Done Q Type of Pump ( H.P. State Work Dane Well Destruction Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) T 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ��--Tl Distance to nearest: Well Foundation Property Line DESTRUCTION +-.1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED [:] Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS M 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 Lqcal 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 work for which this permit is is d, I shall employ persons subject to workman's compensation laws of California." The applicant s call for a yyi/1, aired ' spectio Complete drawing V reverse si e. Signed X F itie te: R DEPART S O o Application Accepted tg 466-6781 Additional Comments: ❑ odi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie t : Env i onmental Hea1f?R wwwit/Services 1601 E. zel on Ave_ P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO —: k-i S. c]aft-Z EH 13-24 REV. 10/82 14-26 10/82 500