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APPLICATI01' FOR PERhIiT SAN JOAQUi`1 LOCAL HEALTH DIS14I' 16C1 E. HAZELTON AVE., STOCKTON, CA SEP 2 6 ISS , MIT N0. Telephone (209) 466-6781 %3 PERMIT EXPIRES 1 YEAR FROM DATE .S DATE ISSUED N tccA (Complete in Triplicate) ��-714 , t 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. Job Address A n Name Owner's Name Address Contractor`s N e License No. os-4, Phone r 3 6' TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR , OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ? i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Industrial U Open Bottom [Manteca Dia. of Well Excavation QuDomestic/Private Gravel Pack Tracy Dia. of Well Casing L7 Public CJ Other Delta L Irrigation Type of Casing� 9 Approx. Eastern Specifications Cathodic Protection Depth p Geophysical Depth of Grout Seal Lf Other Type of Grout &—A A Repair Work Done Type of Pump 46-1 H.P. -� _ _ State Work Done��tla(/C Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) } Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK EJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM rr----11 Distance to nearest: Well Foundation Property Line DESTRUCTION k LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line n SEEPAGE PITS Cj Depth Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. [ hereby certify that ] have prepared this application and that the work will be done in accordance with San Joaquin county 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, 1 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 applic t t call for all required inspections. Complete dr ing on reverse side. Signed X Title: _ �I Date: R DEPARTM99USE ONLY / Application Accepted by Area _ `� 0 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by _ .GA4MC1nn� Date 12 3A=db� Tracy 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. INFO EH 13-24 REV. 10/82 10/82 500 14-26