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i / APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. -�9 Telephone (209) 466-6781 — ' 1 Z� PERMIT EXPIRES 1 YEAR FROM DATE I55UED a DATE ISSUED rl� (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 3 Subdivision Name Owner's Names5WeL 4�c' , .i, Address ` Phone Contractor's Name fg,r yf -1P,, License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1I f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + Industrial ❑Open Bottom (]Manteca Dia. of Well Excavation ❑ Domestic/Private [:]Gravel PackTrac ❑ Y Dia. of Well Casing ❑ Public ❑Other ❑ Delta F1 irrigation Approx. ❑ Eastern Type of Casing ❑Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U 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: 4e Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal (L, Distance to nearest: Well Foundation Property Line P LEACHING LINE No. & Length of,lines p Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth 2=5— Size "I Number / e SUMPS ❑ Distance to nearest: Well Foundation Property Line T� I DISPOSAL PONDS Ofi 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!s 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 i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant ust c?P for re aired inspections. Complete dra g o reverse e. Signed X Title: / Date: �,. F PARTMENT USE ONLY Application Accepted by Area Q, _Stk 466-6781 Additional Comments: Pit or Grout InspectiE] Lodi 369-3621 on by Date �Ju ❑ Manteca 823-7104 Final Inspection by Date Z6- f ❑ Tracy 835-6385 Applicant - Return all copies to: `Environmental Health 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 EH 13-24 REV. 10/82 14-26 10/82 500