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APPLICATION FOR PERMIT SAN JOAQUI LOCAL HEALTH DISTRICT PERMIT N0. 1< 1601 E. HAZELTON AVE., STOCKTON, CA � l t Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED + (Complete in Triplicate) de in compliance-with Local San Joaquin County drdinance No. 549 for sewage or No. 1862 for well/pump Application is hereby made to'ShmaSan Joaquin Local Health District far a permit to construct and/or install the work herein described. This application and the Rules and Regulations of the San Joaquin Local Health District. Subdivision Name Phone �J Job Address �"r/ Address phone Owner's Name License No. Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ Qi_ j TYPE OF WELL/PUMP WORKT NEW WELL ❑ OTHER PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,9ROp, LINE fSEWER LINES .DISPOSAL FLD. �_ f DI5TANCE TO NEAREST: SEPTIC TANK . � OTHER WELL PITS/SUMPS FOUNDATION AGRICULTURE WELL._� INTENDED.� USE - TYPE OF WELL PROBL_ EA -CONSTRUCTION SPECIFICATIONS 0 Manteca Dia. of Well Excavation Industrial- [f Open.,Bottom . _.�.� Tracy Dia. of Well Casing ❑ Domestic/Private Gravel. ack ❑ 4 ❑Other Delta Type of•Casing Public Eastern Specifications De Lj Irrigation Approx. ❑ Depth Depth of Grout Seal Cathodic Protection Type of Grout Geophysical ❑Other Surface Seal Installed by � H P State Work Done O Repair Work Done ❑ Type of Pump �.� C) Sealing Material (top 50') Well Destruction ❑ Well Diameter .— Filler Material (Below 50') Depth No septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION ( available within 200 feet.) X Other (� i Installation will serve: Residence _ CommercialLot size 0 it Number of bedrooms �___ Water table depth Number of living units: �� .J Character of soil to a depth of 3 feet: Capacity 1— No• Compartments 4 SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal r PKG. TREATMENT PLT. ❑ Type/Mfg Foundation �� Property Line. SEWAGE SYSTEM C1 Distance to nearest: Well O DESTRUCTION f Total length/size O . LEACHING LINE 54 No. a Length of lines Property Line _-_� FILTER BED ❑ . Distance to nearest: Well Foundation _ Size Number _ SEEPAGE PITS ❑ Depth _��.� Property Line SUMPS L} Distance to nearest: Well Foundation k DISPOSAL PONDS ❑ be done i I hereby certify that I have prepared this application and that the work will n accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Districterformance of the work for which this Home owner or licensed agent's signature Certifies the following: I certify that in the performance of the work for which permit is issued, I shall not employ ansignason ture�certifiesnthe followbing melsceer{ifyto at in the compensation laws of California. Contractor's hiring or sub-contracting persons subject to workman`s compensation laws of California." this permit is issued, I shall employ p The applicant must call for all required inspections. Comp let ewin��ever �ide. Date: �� Title: Signed X P/Stk 466-6781 DEPARTMENT USE ONLY Area Application Accepted by Lodi 369-3621 Additional Comments: S Date ❑ Manteca 823-7104 Pit or Grout Inspection h Tracy 835-6385 �- Date .� �•} � (— Final Inspection by p.0. Box 2009, 5tk., CA 95201 Applicant - Return all Copies to; Environmental Health Per 16 1 E. Hazelton Ave.+ PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE k INFO ` 3-3Fsl r /• 10/82 500 Eh 13-24 REV. 10/82 /�f s6c CYA"/4-I 14-26 r