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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 Regulations of the San Joaquin Local Health District, Job Address Dv ubdivision Name Owner's Name Geo Address _ ��4/ r5' dwe 4 Phone Contractor's NameAge License No. J� � TT� Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [ SYSTEM REPAIR r 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- Open Bottom ❑ Manteca Dia. of Well Excavation e Domstic/Private ti U � Gravel Pack � Tracy • Dia:•of--We11kCasing Public ❑ Other (�Delta Type of Casing ❑ Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal ❑Geophysical ,❑ Other Type of Grout s- i 14 4 Surface.Seal Installed by L Ln Repair Work Done ❑ Type.of Pump H,P. State Work•Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is v available within 200 feet.) Installation will serve: Residence e Commercial _ Other Number of living units: �' Number of bedrooms 1. _ Lot size Character of soil to a depth of 3 feet: /Q pC+Q'C _ Water table depth } SEPTIC TANK FZJ Type/Mfg P, �i Capacity �� No. Compartments PKG. TREATMENT PLT. Type/Mfg. ' " r': Capacity Method of Disposal SEWAGE•SYSTEM Distance to nearest: Weld Foundation /15— Property Line DESTRUCTION ❑ ''�'] LEACHING LINE Ek No. & Length of lines __- �(> Total length/size .L flZr )MV— FILTER BED ❑ Distance to nearest: -Well jUpF Foundation Property Line SEEPAGE PITS Cj Depth ja } .size . 'Number- SUMPS Number-SUMPS Distance to nearest: WellFoundation ja` 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 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant must tali fo11 r fired " pections. Complete drawing on reverse side, �f Signed'X Title: ��,.1,K:C � �" Date: Z "L 112 FOR D RTMENT USE ONLY Application Accepted by Area o7- Stk 466-6781 Additional Comments: ❑ Lodi 359-3621 s Pit or Groat Inspection by Date Manteca B23-7104 Final inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environme 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 EH 13-24 REV. 10182 10/82 500 14-26