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APPLICATION FOR PERMIT SAN JCAQLIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO., ��-- S Telephone (209) 466-6781 DATE ISSUED — � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applicatior 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 the San Joaquin Lo 1 Health District. Job Address /V ; Subdivision Nam Owner's Name Address f �3Al Phone i Phone C Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ i' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE_._ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom Manteca Dia. of Well Excavation U ❑ [ ` Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing v ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout seal ❑Geophysical Type of Grout I ❑Other Surface Seal Installed by Repair Work Done G 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 ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is F 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 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 y LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [P� Depth 2,S Size 3 Number _ SUMPS ❑ Distance to nearest: Well /foundation 1 Property Line DISPOSAL PONDS ❑ f "7"`- 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 workmans compensation laws of California." ' e certifies the following: "I certify that in the performance of the work for which Contractor's hiring or sub-contracting signatur ' this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant 34st call for all r fired inspections. Complete drawing on reverse side. Signed X < <JCs Title: Date: F EPARTME T USE ONL / ❑ Stk 466-6 1 Application Accepted by� Area [ Additional Comments: (((((( X Lodi 369-3521 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final inspection by Date F y � Tracy 835-6385 Applicant - Return all copies to: . Environmental He th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rFE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. O Lis, 10/82 500 EH 13-24 REV. 10/82 14-26