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APPLICATION FOR PERMIT SAN JOAQL'IN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 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 Cou y Ordinance No. 549 for sewage or Qyt, 11/pump and the Rules and Regulations of the San Joaquin Loc 1 Health ist.5itt. M Job Address �.GO�.[ �E �Zien Mmec . Co03 Owner's Name LNfi , Address Contractor's Name SQL( • icen�se N yr-1- _ TYPE OF WELL/PUMP WORK: NEW WELL [] WELL EPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation 4611ce• Domestic/Private ❑Gravel Pack F_�Tracy Dia. of Well Casing Public [Fel Other K� ✓4 ❑ Delta Type of Casing IrrigationK, Approx. []Eastern — Depth Specifications Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction A Well Diameter Sealing Material (top 50') .Sc'� Depth Filler Material (Below 50' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION fJ (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 PKG. TREATMENT PLT. �f Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line rn DISPOSAL PONDS ❑ � 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 applica must 1 for all required inspections. Complete drawing on reverse side. Title: �� Date: ZZ— Signed X '�'/ G r_ x FOR DEPARTMENT USE ONLY pl cation Accepted by Area Stk 466-6781 ditional Comments: 1 Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date/ Tracy 835-6385 Applicant - Return all copies o: Environme al ealth Permit/Services 160 "azeltonAve., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ra a2 Z rI 3n/ r OJ EH 13-24 REV. 10/82 10/82 500 14-26