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APPLICATION FOR PERMIT SAN JOAQOIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED— 17 —Q� (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 Job Address the San Joaquin Local Health District. Job Ade Rules a72 Regulations of 3 5-7j Subdivision Name Owner's Name -7%-.-*i,GlC� Address Sv1 1� , � Phone Contractor's Name i n. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1=J Industrial U Open Bottom D Manteca Dia, of Well Excavation Lf Domestic/Private Gravel Pack 0 Tracy Dia. of Well Casing Public �j Other Delta Lj IrrigationType of Casing Approx. � Eastern ❑ Cathodic Protection Depth Specifications ❑ Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done E] 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 ❑ (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: Number of bedrooms Lot size Character of soil to a depth of 3 feet: SEPTIC TANK LJ Type/Mfg Capacity PKG. TREATMENT PLT. ❑ Type/Mfg Capacity SEWAGE SYSTEM ja Distance to nearest: Well Foundation DESTRUCTION Water table depth No. Compartments Method of Disposal Property Line 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 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 employ persons subject to workman's compensation laws of California." The applic must call for %4rquired inspections. Complete d�rajwing on reverse side. Signed X /L�. L l✓ Title: 11(��3-y�p�,< Date: CQ11,1 d Application OR DEPART ENT USE ONLY Accepted by / G Area Stk 466-6781 Additional Comments: r_1 Lodi 369-3621 Pit or Grout Inspection by POP Date LD Manteca 823-7104 Final Inspection byDate . ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health P mit/Services IfOl E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO ND EH 13-24 REV. 10/82 01 a/(4'�1. CJ lSCK � Y�q 10/82 500 14-26 J 04 )