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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q '] 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 /7 /V, Subdivision Name Owner's Name Address ems. Phone Contractor's NamLicense No., Z-2_(V Phone��' .$jj__ o�) TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 1 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 iD Industrial Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing 0 Public Other Delta U Irrigation Approx. Eastern Type of Casing Fj Cathodic Protection Depth Specifications -� Depth of Grout Seal Geophysical Type of Grout �Other Surface Seal installed by Repair Work Done Ef Type of Pump N.P. State Work Done Well Destruction U WelI-Dtameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE Of SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION — {No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence kee'�" available within 200 feet.) Commerciai Other � Number of living units: _�— Number of drooms _J Lot sizeW CL<_4 ,4a Character of soil to a depth of 3 feet: �� ._ Water table depth zl» SEPTIC TANK Cj Type/Mfg +� Capacity No, Compartments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal Distance to nearest:. Well Foundation Property Line LEACHING-LINE L 1 No.,& Length of lines Total length/size FILTER BED Distance to nearest: Well # Foundation Property Line SEEPAGE PITS Depth A,1;7- .. Size 3(a Number 7 p6 SUMPS LJ • Distance to nearest: Well 14-f Foundation 10 Property Line S 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 mann6r as to become subject to workman� compensation laws of California." Contractor's hiring or s`ub-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 applic nt must all for all required inspections. Complete drawingon reverse side. Signed X Title: U Date: / 2 — FOR DEPARTMENT USE ONLY App ication Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspectionp) I Date Manteca 823-7104 Final Inspection by Date [] 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 EH 13-24 REV. 10/82 10/82 500 14-26