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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��` �✓� Telephone (209) 466-6781 y ?(3 ,2 DATE ISSUED QC..,� PERMIT EXPIRES I 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 Re ulat.ors of San Joaquin Local Health District. s�G� Job Address �l ! Subdivision Name Owner's Name f Address C Phone _ Contractor's Name ; ; License No. Phone T TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION pd PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U 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 L1 J Industrial U Open Bottom ❑Manteca Dia. of Well Excavation cl Domestic/Private Gravel Pack Tracy Dia. of Well Casing W L] Public FJ Other [:] Delta Type of Casing F, Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal U Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Doone Well Destruction Well Diameter Sealing Material (top 50') [ gyp/&,p.0 f 'C Depth �,� _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS D Depth Size Number SUMPS U 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 it 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 workmanR 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 this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applican st ca 1 f 11 required inspections. Complete drawin on ^e erse side. ,/ Signed Title: . Date: FOR RFPARTMLNT USE ONLY Stk 466-6 81 Application Accepted by Area Additional Comments: Lodi 369-3621 Pit or Grout Inspec ion Date 2 U Manteca 823-7104 Final Inspection by DateTracy 835-6385 / ❑ Applicant - Return all c 'es E vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE A NT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 EH 13-24 REV. 10/82 14-26