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APPLICATION FOR PERMIT SAN JOAQUIN 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 County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the S n J On Local HQalth District. Job Address Z/ KA �! Subdivision Name Owner's Name Address /�© �X �V,2 Phone - Contractor's Name r License No, y Phone 3?ZZ-2,V10 C� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 7 DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES �O /-{ DISPOSAL FLD.�6d PROP. LINE _ FOUNDATION /� ` �- AGRICULTURE WELL SO'�_ OTHER WELL PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 ^VVI FlIndustrial U Open Bottom /Dt Dia. of Well Excavation IVI Domestic/Private Gravel Pack Dia. of Well Casing j` 17 Public Other �Irri ation Type of CasingII 9 ,fes Deprox. Specifications I F-ICathodic Protection Depth p !' A S s 1-1 Geophysical Depth of Grout Seal Other Type of Grout C Eivt E„t Surface Seal Installed by QlR I /&a Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION l—1 (No septic tank or seepage pit permitted if public sewer is 11 1 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 SEPTIC TANK �j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Septic Tank Distance to nearest: Well Foundation Property Line Destruction LEACHING LINE LJ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS LJ 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 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 emplo` persons subject to workman's compensation laws of California." The applica ust cal nfo all a ired inspections. Complete drawing on reve se side. Signed Title: /I N Date: FOR E ARTMENT USE ONLY Application Accepted by Area _ 06 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date —�j Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant Return all copies to: Environmental Heal?h 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 60 1 EH 13-24 REV. 10/82 10/82 500 14-26