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APPLICATION FOR PERMIT SAN JOAQLiP LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 � k j DATE ISSUED J 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 the San Joaquin Local Health District. Job Address (,trw. Subdivision Name Owner's NameAddress Phone Contractor's Name License No. 47�Cj -- 3ele.3 / Phone 797 , �Q TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR j ' OTHEROVCt ��Ic DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L7 �- DISPOSAL FLD. � PR P. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 10,C) / PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial pen Bottom Manteca Dia. of Well Excavation Y F—IDomestic/Private F—] Gravel Pack Tracy Dia. of Well Casing Public Other Cl Delta Type of Casing t` Eve<rligation Approx. E] Eastern Specifications _ F—ICathodic Protection Depth Geophysical AI //, i � t� �� Type of fGrout Seal ofGrout /� rT LJ Other /v Surface Seal Installed by Repair Work Done [J Type of Pump P. _1l State Work Done Well Destruction Lf Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION [_J (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 F Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM 11—�1 Distance to nearest: Well Foundation Property Line DESTRUCTION U LEACHING LINE U 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 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 workmant 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 e ploy persons subject to workman's compensation laws of California." The applicant s call for 1 equir d iri6pections. Complete dra g on re erse side. , Signed X Title: /�4/ jE Date: FOR DE ARTMENT USE ONLY Ap ication Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date _"Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies o �: En onmental Health Permit/Services 160 E�Halto ve., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. W INFO 7. ko 10/82 500 EH 13-24 REV. 10/82 14-26