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APPLICATION FOR PERM; S��r'�J {+ED SAN JDAQLi'; LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. \ �l3 Telephone (209) 466.-6781 y"n\ PERMIT EXPIRES i YEAR FROM DATE ISSOED 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 �, Subdivision Name Owner's Namea at Address Phone Contractor's Name ► License No. Phone 7.1]— ±;� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION / SYSTEM REPAIR U OTHER �Q/�1�— U,PGII DISTANCE TO NEAREST: SEPTIC TANK 4- SEWER LINES DISPOSAL FLD. PR P. LINE �' / •� FOUNDATION AGRICULTURE WELL OTHER WELL �Z�p PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Af I j Industrialpen Bottom []Manteca Dia. of Well Excavation f¢ Domestic/Private M U ❑ Gravel Pack � Tracy Dia. of Well Casing jtj.Public E1 Other ❑ Delta �� rr� anon Type of Casing •�! a/ x�� LK 1 g Approx. Eastern Cathodic Protection Depth Specifications Al — Geophysical �� Depth of Grout SealQ_j U Other � � Type of Grout Surface Seal Installed by Repair Work Done Type of Pump &&4' + .P, °J.f1 State Work Dane Well Destruction U Well Diameter *!2= Sealing Material (top 50') Depth 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 _ Other Number of Hiving units: Number of bedrooms Lot size Character of soil to a-depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [7j Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER AED Distance to nearest: Well Foundation Property Line- SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED 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 e ploy persons subject to workman's compensation laws of California." The applicant s call for 1 equir d ir}6pections. Complete dr a g on re erse side. Signed K ► Title: Date: FOR DE ARTMENT USE ONLY } Ap ication Accepted by Area L] Stk 466-6781 Additional Comments. Lodi 369-3621 Pit or Grout Inspection by Date 'L rteca 823-7104 Final Inspection by 00 1, Date ❑ Tracy 835-6385 Applicant - Return all copies o: En onmental Health Permit/Services 160 E. Ha !tan Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. t' INFO 7rb7 W P EH 13-24 REV. 10/82 10182 500 14-26