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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED JILL 21 1983 (Complete in Triplicate) JUL' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the veN ,rhe T ��tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well pump and the Rulesr�>�� 1I ESS aquin Local Health District. 1% t {( Job Address1710 City Lot Size PM Owner's Name Address Phone Contractor��` _ � t— rAdtlress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom Cl Manteca- Dia. of Well Excavation Dia. of Well Casing /_DomesticlPrivate — 0-Gravel Pack--E1--Tracy:,. - Type-cit Casing_ _ _ Specifications ("1 Public 7 Other ❑ Delta Depth of Grout Seal � "Type of Grout I I Irrigation ''Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(fop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1. DESTRUCTION I i iNo septic system permitted if public sewer is available within 200 teet.l Installation will serve: Residence— Commercial_ Other f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE . ❑ N6, & Length"of lines Total iength/size FILTER BED ❑ Distance to nearest: " Well Foundation Property Line f SEEPAGE PITS 1 I Depth Size _ Number SUMPS Ll 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'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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must for all re uired%n ctions. Complete drawing on pse side. Signed Title: Date: 7_-1 . " FORDEPAOTIVIENT USE ONLY ? •` C� a / Application Accepted by. _ Date 7-74-y'? Area Pit or Grout Inspection lny Date "� 7.-Final Inspection by - Date/G 3/ Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO / CASH r/7 + EH 13-21(REV.i i p 5) "224 N—lyy � EH 14-26 - r