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APPLICATION FOR PERMIT SAN jOAQLi;: LOCAL HEALT`i DISTRICT -p 7> / 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT N0, 0 Telephone (209) 466-6781 g DATE ISSUED ~73 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 thcal Health District. Job Address e Sa Joaquin Lo e� S division Name Owner's Name E Address /��' 7A� �� + _ Phone Contractor's Name License No. � �-�-� _ Phone TYPE OF WELL/PUMP WORK: NEW WELL. WELL REPLACEMENT DESTRUCTION L CSS PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER LJ 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 17 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing t] Public ❑ Other Delta Type of Casing L] 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 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION T1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is —� available within 200 feet.) V} Installation will serve: Residence _ Commercial Other r Number of living units: Number of bedrooms Lot size S -� Character of soil to a depth of 3 feet: �iL� ��l� _ Water table depth SEPTIC TANK !� Type/Mfg Capacity No. Compartments 4J• PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well S oundation /!d Property Line DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Fourdation - Property Line SEEPAGE PITS Depth Size 3 Number /! SUMPS Distance to nearest: Well oundation 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�, compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fallowing: "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 mu t call for all r �qu/ired inspections. Complete drawing or reverse side. Signed x Title: Date: FOR DEPARTMENT USE ONLY ] Application Accepted by Area! ❑ Stk 466-67B1 Additional Comments: T �Lodi 369-3621 Pit or Grout Inspection Date U Manteca 823-7104 Final Inspection by Dateff� L} Tracy 835-6385 Applicant - Return all copies o: Environmental Health Permit/Services 1501 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 =BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ;PERMIT NO. '45 -la�FS EH 13-24 REV. 10/82 I0182 500 14-26