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A, APPLICATION FOR PERMIT SAN JOAQUih 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/R�gulations of the San Joaquin Local Hea th istrict. Job Address F4 N of, OX CK' Eftb ivision Name Owner's Name C Address Phone ISIV Contractor's Name License No. Phone re j!Z .7 TYPE OF WELL/PUMP WORK: NEW WELL: WELL REPLACEMENT ❑ DESTRUCTION ❑ 6-3-L- 773-L PUMP INSTALLATION,. a SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES rT DISPOSAL FLO. — PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (/ Industrial ❑ 0 en Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public [—I her Delta + �J ❑ Type of Casing E Irrigation Approx. ❑ Eastern Specifications r ❑ Cathodi.c Protection Depth Eiza4"w Depth of Grout Seal gme ❑Geophysical Type of Grout LL41wp W, ❑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 U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 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: Mater table depth ('J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC, TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line fi SEEPAGE PITS ❑ Depth Size Number SUMPS Ll Distance to nearest: Well Foundation - 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 following: "I certify that in the performance of the work for which �J this permit is issued, I shall employ4��i persons subject to workman's compensation laws of California." The applicant all llomplete drawi +on reverse side. Signed X tle: Date: �- R DEPA ENT USE ONLY Application Accepted by Area ❑ Stk 466-6781 - Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date �� Manteca 823-7104 Final Inspection by Date ( ❑ Tracy 835-6385 Applicant - Return all copiesF: nv,r.nmnt.l Health Permit/Services 1601 E. azelton 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