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APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -50 Li Telephone (209) 466-6781 DATE ISSUED � rte' -I-T LA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate.) l ' 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 an oaqui.n Local Health Distoi Job Address /7 — v,s' n - Own6r's Name 41&4 A -1 Address T Phone Contractor's Name License No. �E�$/ _ Phone i TYPE70F WELL/PUMP WORK,.,. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER n DISTANCE TO NEAREST: SEPTIC TANK �j�'f SEWER LINES DISPOSAL FLO. � PROP. LINE ;FOUNDATION:' AGRICULTURE WELL OTHER WELL "PITS/SUMPS INTENDED USE '" AYPE 0) WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation 1 LXDomestic/Private ` [gavel Pack 5eracy Dia. of Well Casing ❑ Public Other ❑ Delta U E] Type of Casing C Irrigation Approx. Eastern ' ❑Cathodic Protection Depth Specifications 0 Depth of Grout Seal 0 t ❑Geophysical Type of Grout 9'I" Z7i1- t p ❑Other Surface Seal Installed by 'GC• _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) �l i q Depth Filler Material (Below 50') w ! TYPE OF SEPTIC WORK: NEW INSTALLATION jJ REPAIR/ADDITION U (No septic tank or seepage pit permitted"if-public sewer is t i 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 g SEPTIC TANK ❑ Type/Mfg Capacity—' No. Compartments PKG.,TREATMENT PLT. ❑ Type/Mfg -..capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE l f No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth �a ;.Size Number SUMPS U Distance to nearest: -Well Foundation Property Line DISPOSAL PONDS ❑ w .:tti� 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 this permit is issued, I shall employ persons subject to workman's compensation laws of California." The appl' t mus call foA13 required inspections.,,Complete drawing on reverse side. ^� Signed �7Title: Date: - J "ENT USE ONLY Application Accepted by Area ❑ 5tk 466-6781 Additional Comments: ❑ Lodi 369-362.1 Pit or Grout Inspection by -,.+ Date ` ❑ Manteca 823-7104 Final Inspection by _Date li�,``1'racy 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. i INFO L4 . o x'11all-s o LA EH 13-24 REV. 10/82 �12 44- 10/82 500 14-26 `\