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APPLICATION FOR PERMIT - f SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT NO. 93 -369 1601 E. HAZELTON AVE., STOCKTON, CA 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 a and the Rules and Regulations ofdthe�,5an J quiff cal Health District. Jab AddressG� � Subdivision.Name Owner's Name % �` Address � Phone Contractor's Name License No. Z _ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR�y ❑ OTHER w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES T'� DISPOSAL FLD. PROP. LINE 1 FOUNDATION JQ AGRICULTURE WELL F OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6-y f ❑ Industrial [—[open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Other ❑Delta Type of Casing LJ Irrigation k:• .•.r Approx. ❑'Eastern. - - .» -,Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout U 0ther Surface Seal Installed by Repair Work Done ❑ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 93 , � Depth Filler Material (Below 50') �`' k�r �- TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit per itted if public sewer is available within 200 feet) I " Installation will serve: Residence Commercial _ Other G Number of living units: ] Nu er of bedrooms _ �5Lot size e Character of soil to a deepp[th�of 3 feet: i)4 r-- "Water table depth # No. Compartments SEPTIC TANK � Type/Mfg (� z Capa� ty o - ---- PKG. TREATMENT PLT. ❑ Type/Mfg ( Capacity Method of Disposal ,.7� m Distance to nearest: Well Foundation `�PropertyjLine Septic Tank �— ;- — �. � r r ..Total length/size LEACHING LINE [ No. & Length of lines FILTER BED [] Distance to nearest: Well Foundation Property,'Line SEEPAGE PITS ❑ Depth' Size Number s SUMPS Ll Distance to nearest: Well Foundation Property;Line y: 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 performanceyof the work for which this permit-is issued, I shall not employ any person in such'-inanner-as to 5ecome 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 applicant must call �or- require inspections. Complete'drawing on reverse side. °- ��, fir, k. Signed X Title: �� Date: _ 4111 .1 EP TMENT USE ONLY � � Application Accepted by - Area .—� ❑ Std 466-6781 Additional Comments: El Lodi '369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by _ Date ❑ Tracy 835-6385 Applicant Return all copies to: ,Environmental h Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 f FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY- DATEp ;:P ERMIT!N0.INFO 'c�7 l9-� ",... EH 13-24 REV. 10/82 10/82 500 14-26