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, APPLICATION FOR PERMIT 1 SAN JOAQUiN LOCAL HEALTH DISTRICT 4 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0, Vey Telephone (209) 466-6781- ,k 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED i (Complete in Triplicate) Application is herebylgmade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicat'jion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and.Regulat`ions of the.San Joaquin Local Health District. Job Address_ /,96'r" �I li Subdivision Name Owner's Name Cx�ur Address Phone Contractor's Name License No. —73 9j3 Phone r .F -TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ ^� Try PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTiIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l!' ' i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 > INTENDED USE il TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I J Industrial a Open Bottom Manteca Dia. of Well Excavation O? ❑I Domestic/Private II ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public �� ❑Other ❑Delta Type of Casing Irrigation Approx. []Eastern ED Cathodic Cathodic Protection Depth Depth of Grout Seal I❑Geophysical it Type of Grout I_IOther Surface Seal Installed by Repair Work Done ❑ Type-of-Pump H.P. State Work Done well Destruction I❑I Well, Diameter Sealing Material (top 50') d Depth Filler Material (Below 50') f n TYPE OF SEPTIC WORK: i6 NEW' INSTALLATION ❑ REPAIR/ADDITION LA (No septic tank or seepage pit permitted if public sewer is L/ i; INavailable within 200 feet.) Installation will Serve: Residence _ Commercial X_ Other Number of living unitsi:I Number of bedrooms Lot size Character of soil to a�ldepth of 3 feet: G _ Water table depth �- SEPTIC TANK ❑ IType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. .i 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 r FILTER BED Ed Distance to nearest: Well — Foundation' Property Line W SEEPAGE PITS Depth -- Size Number �__3 - SUMPS U Distance to nearest: Well Foundation -- Property Line [ DISPOSAL PONDS CI �, rw ra�un I hereby certify that I Piave 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 r permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." 4 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which Y this permit is issued, 1:s hall employ persons subject to workman's compensation laws of California." The applicant must cal for all uired in.5pections. Complete drawing on everse si Signed X ;I Title: Date: Z"> 0 EPARTMENT SE ONLY Application Accepted by Area5tk 466-6781 m ti ❑ Additional Comments: Lodi 369-3621 Pit or Grout Irnspection by Date L7Manteca 823-7104 Final Inspection By Date ❑ Tracy 835-6385 k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1€ rFTEE � BASE J�AMOUNT DUE AMOJNT REMITTED RECEIVED BY DATE PERMIT NO. F sEH 13-24 REV. 10/82 10/82 500 14-26 1I