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APPLICATION FOR PERMIT SAN JOAQCIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ��1 Telephone (209) 466-6781 DATE ISSUED � O•- 11�� 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 t e Szn Joaqui Local Health District, Job Address �--C% `^ Subdivision Name Owner's Name r �- dress � �� Phone Contractor's NLicense No. _ 7 Phone A TYPE OF WELL/PUMP WORK: NEW WELL F-] WELL REPLACEMENT DESTRUCTION �N PUMP INSTALLATION F-] SYSTEM REPAIR OTHER U _- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE R , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I_J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation lJ Domestic/Private 7 Gravel Pack ❑ Tracy Dia. of Well Casing Public ❑Other 0 Delta Type of Casing Irrigation Approx. E]Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal 17 Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done [J Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') V I Depth Filler Material (Below 50') 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: --,Z — Number of bedrooms ?i Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK U Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ 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 BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS EK Depth Z J r Size 56 Number SUMPS LI Distance to nearest: WellQ 4L Foundation Property Line DISPOSAL PONDS D 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 workmanIs 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 per is iss ed, I shall employ persons subject to workman's compensation laws of California." The applicant m call for all r it d inspections. Complete drawing on reverse side. Signed X Title: Date: :7' FO PARTMENT USE ON Application Accepted by _09 Area / Stk 466-6781 Additional Comments: Z� Lodi 369-3621 Pit or Grout Inspection by Date U Manteca 823-7104 Final Inspection by ��P Date Tracy 835-6385 Applicant - Return all copies o: Environmental Heal h Permit/ ices 1 1 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