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t � o- APPLICATION. FOR PERMIT _ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (249) 466-6781 GATE ISSUED PERMIT EXPIRES 1,YEAR FROM DATE ISSUED i (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 Sann/Joaq in Loc Health strict. Job Address / (Q G /srT� _ �`Su i-visiorL Name q `L r Address Phone Owner's Name _ Contractor's Name C License N0. _ Phone TYPE OF WELL/PUMP—WORK; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER FJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1-1 l �! Industrial ❑ Open Bottom Manteca Dia. of Well Excavation tpl 47 mestic/Private E] Gravel Pack Tracy 'Dia. of Well Casing hlic �j Other ❑ Delta Type of Casing - _V Irrigation Approx. [] Eastern Specifications 7 ❑ Depth Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by -a� �� ►� Repair Work Done ❑ Type of Pump H-P, State Work Done ~ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic__tank or seepage pit permitted if public sewer is� r- available within .200 feet.) Installation will serve: Residence Commercial _ Other ((its Number of living units:, Number of bedrooms Lot size V character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PIT. ❑ Type/Mfg Capacity Method of Disposal 1 SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION ' LEACHING LINE F-1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U 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. Rome 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 emp oy persons subject to workman's compensation laws of California." The applican st all f a r quired inspections. Complete drawing on reverse side. \ Signed X Title: ' ��• Date: ,— OR ARTMENT USE ONLY �� ❑ Stk 466-6781 'Application Accepted by l Area [] Lodi 369-3621 , Additional _Comments: on by Date � ❑ Manteca 823-7104 Pit or Grout Inspecti i Date L 7 Tracy 835-6385 Final Inspection by ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �r r�PEERMIT NO. INFO r d�,� ■oft $��`U� lip 0zT 6f M/ 10/82 500 EH 13-24 REV. 10/82 14-26 r