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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON .AVE., STOCKTON, CA PERMIT N0. U t Telephone (209) 465-61814 ![k DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) ti 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 San Joaquin Local Health District. I Job Address i �~ Subdivision Name Owner's Name J Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ rrQ PUMP INSTALLATION r� SYSTEM REPAIR ❑ �OTHER, [J DISTANCE TO NEAREST: SEPTIC TANK � �+ SEWER LINE5 � DiSPOSALrFLD. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation S 'Domestic/PrivateGravel Pack ❑ Tracy Dia. of Well Casing o ❑ Public Other Q Delta �F•'.Type of Casing ❑ Irrigation " Approx. Q Eastern, `k Specifications ❑ Cathodic Protection Depth } Depth of Grout Seal U Geophysical - Type of Grout f ❑Other �"'" � , Surface Seal -Installed by ..- Repair Work Done ❑ Type of Pump H.P.-..—, t" State Work]Done t +' r Well Destruction U Well; Diameter " {Sealing Materiall(top 50') } �Dept'h Filler-Material-^(Below 50') � TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION (.No septic tank or seepage pit.permitted if public sewer is available within 200 feet.) Installation will serve: Residence �( Commercial �7 Other Number of living units: Number of bedrooms Lot sizer Character of soil to adepth of 3 feet: 'Ve Water table depth t SEPTIC TANK ❑ .i Type/Mfg F Capacity f" ' No..,`Compartments 1 PKG. TREATMENT PLT. ❑ Type/Mfg E Capacity 4 Method of Disposal` SEWAGE SYSTEM ':Distance to-nearest: Well < ,4 Foundation &C, -7_0 t DESTRUCTION LEACHING LINENo. & Length of lines CJ f i Total length/size ! FILTER RED Distance to nearest: Well Z_ Property 'Line_ m _— SEEPAGE PITSf Depth S Size � - ' _ Number"X / a 7 k SUMPS U Distance to nearest: Well ,��8 r Foundation�"`a1' s Property Line I DISPOSAL PONDS I herebycertify that 1 have prepared this-application and that the work-wiJI be done in accordance with San Joaquin county ordinances, state laws, and rules`andyregulations 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 far which this pert mitisissued, I.shall not employ any person in such manner as to become subject to workmanb compensation laws of California." contractor's hiring or s'ub-contracting signature certifies the following: ",1"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 Ca'l'ifornia." The applican r t call ?for''all requ'red in pections. Complete drawin n r e se side. 5igned�X Title: Date: 4 3 i EPA TM ENT ONLY ❑ Application Accepted Area 5tk 466-5781 Additional Comments: I ZZ, ❑ Lodi 369-3621 Pit or Grout Inspection by Date/ .S — ❑ Manteca 823-7104 Final Inspection by Date A9__ - 3 Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 i f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIIT NO. INFO 1' � �-�3✓�� r-� r 10/82 500 EH 13-24 REV. 10/82 14-26