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APPLICATION FOR PERMIT " SAN JOAQUIN LOCAL HEALTH DISTRICT 1� 1601 E. HAZELTON AVE., STOCKTON, C 11I PERMIT NO. -3 L1 0 Telephone (209) 466-6781 0] 'j4 to' E ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED AN J O Q R1,, (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. ) !l Job Address r '' - Subdivision Name Owner's Name Ni I4 Address Contractor's Name Lit— icense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALL SYSTEM REPAIR OTHER EJ DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLP, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Industrial E] Open Bottom Manteca Dia. of Well Excavation mestic/Private 0 Gravel Pack Tracy Dia. of Well Casing r Public F-1 Other Delta '1 L1 Irrigation Approx. ❑Eastern Type of Casing Depth Specifications Cathodic Protection p Geophysical !� q a Depth of Grout Seale .�.�.,.�� _.� #` Other ! Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump. � State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) f I 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line { DESTRUCTION LEACHING LINE ❑ " No. & Length of lines, Total ,length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS IJ 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 law's, 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 I 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 signat re certifies the following: "I certify that in the performance of the work for which this permit is ' sued, I shall employ persons subject to workman's compensation laws of Californi --�; The applica c 11M&P u' ed in ct' ns. Complete r wing on reverse s' r i Signed X Title: OR.OEPA MENT VSE ONLY Application Accepted by ^� Area Stk 466-6781 3 Z Additional Comments: ;1 E] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date J Tracy 835-6385 Applicant - Return all copies to: Environmental th Permit/Services 1601 E. Hazeltoff'Ave., P-.0. Box 2009, Stk., CA 95201 :i i I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO L4 0 EH 13-24 REV. 10/82 ,, 10/82 500 14-26