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d � APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 Y 1 Y 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 Regulations of he San Joaquin Local Health District, Jab Address f tQ Subdivision Name Owner's Name Address / i _ Phone Contractor's Na License No. �� 7 Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR. LJ OTHER U i DISTANCE TO NEAREST: SEPTIC TANK - - SEWER LINES - '01-SPOSAL-FLD. .PROP_.,,LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom F-� Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other Delta Type of Casing LjIrrigation Approx. Eastern El Cathodic Protection Depth Specifications Oepth.of Grout,S a)) Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') . ._ 4� Depth Filler Material (Below 50') Od TYPE OF SEPTIC WORK: NEW INSTALLATIONEPAIR/ADDITION U (No septic tank or seepage pit permitted-if public sewer 's available within 200 feet.) Installation will serve: Residence _ Commercial _ Other ___ /�jy ��' �f .Y lir �• Number of livingunits: Number of b Broom Lot size �,,`-- -- Character of sail to depth of 3 feet: Water table. depth ,� SEPTIC TANK [ Type/Mfg' Capacity No. Compartments „z PKG. TREATMENT PLT. Type/Mfg Capacity Method oftDispos`al,c- d SEWAGE SYSTEM Distance to nearest: Well $a Foundation Property Line DESTRUCTION sem° — p. LEACHING LINE No. & Length of lines 3 r te ' Total length%size w FILTER BED . ,.,Distance to nearest: well oundation -,Property Line SEEPAGE PITS Depth '� Size. !� Number f + SUMPS U Distance to nearest: Well I_ aJI-:Founda ion v �_{�� Prop rty Line 7f DISPOSAL PONDS F x 4 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 viork•for which this permit is issued, I shall not employ any person in such manner as to become subject to workman, compensation law's 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 applicant must l for all require nspections. Complete drawing on reverse side. Signed X Title: Date: MENT USE ONLY s Application Accepted by Area 12-- ,Stk�'" 466-b�1 Additional Comments: Lodi 359-3621'' -.. `- Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date 4 ❑ Tracy 635-6385 Applicant - Return all copies to: . Environmental H lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. EH 13-24 REV. 10/82 10/82 500 14-26 '