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I APPLICATION FOR PERMIT Q SAN JOAQUiN LOCAL HEALTH DISTRICT J (� 1601 E. HAZELTON AVE., STOCKTON, CA �+ PERMIT N0. )3-S77 Telephone (209) 466-6781 07AN �,�'QUi WPAIEISSUED PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED � DISTRICT (Complete in Triplicate) Application is hereby made'to the San Joaquin Local Health District fora 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 Pealth District, Job Address Subdivision Name Owner's Name Address„ Phone (r Contractor's Name ., S ;License No, �7 afQ/Q Phone �. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ^f� •�! f PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP, LINE 01 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v \ Industrial ❑ Open Bottom Manteca Dia, 'of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public Other Delta Type of Casing 0 irrigation Approx. Eastern L)Cathodic Protection Depth ;Specifications Geophysical Depth of Grout Seal — - F-1Other Type of Grout Surface Seal Installi ed by i Repai"r Work Dane X Type of Pump SL,� H.P. State Work Done $ .j* Well Destruction F-1Well Diameter Sealing Material (top 501) C_ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U E REPAIR/AdDITION U (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 depthof3 feet: Water table depth Y 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 ❑ 1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line t SEEPAGE PITS ❑ Depth Size Number SUMPS 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 F ordinances, state laws., and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the fol.lowing: "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 employ persons subject to workman's compensation laws of California." The appiic mustcallgfoal required inspections. Complete d ron reverse side. , Signed X Title: /1,� Date: F EPARTMENT USE ONLY Application Accepted by r O A �^ Area �] Stk 466-6781 A. Additional Comments: _ _ 0 Lodi 359-3621 Pit or Grout Inspection b DateManteca 823-7104 i Final Inspection by Date . Tracy 835-6385 Applicant - Return all copies to: Environmenta Health Permit/Services 1601 E. H ton Ave., P:O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO cs aI �"- 733-577 EH 13-24 REV. 10/82 10/82 500 14-26