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RMIT APPLICATION FOR PE a ® SAN JOAQUIN' LOCAL.HEALTH-DISTRICT ` ! 1601 E. HAZELTON AVE. STOCKTON, CA PERMIT N0. Telephone (,209)456-6781 _ DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO (Complete in Triplicate) i Application is hereby made to theSanJoaquin 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 u Subdivision Name Owner's Name Address a Phone Contractor's Name License No. Phone of L Jr TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ P6MP INSTALLATION SYSTEM REPAIR L7 OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL" OTHER WELL PITS/SUMPS Qy' Il INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f' Industrial' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L/ ❑� Domestic/Private "❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth; { Depth of Grout Seal""" ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work°'Done DPrType of Pump H.P. State Work Well Destruction ❑ Well Diameter; Sealing Material (top 50') e * i 4. j, ept Filler Material (Below 50') '� ► `- 1 TYPE OF SEPTIC WORK: NEW`INSTALLATION ❑ REPAIR/,40DITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve:? Residence Commercial _ Other L� 4, Number of living units: Number of bedrooms Lot size d ! Character of soil to a depth of.3 feet: Water table depth _ �. . � SEPTIC TANK � [J Type/Mfg "..f,�iS��Nj�"`" �"`"Capacity'"""�" No.- 't's,, PKG. TREATMENT PLT. ❑ Type/Mfg Capacity k Method f,Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Prop ty Line DESTRUCTION LEACHING LINE` .4.No. & Length of lines r ,Total length/size FILTER BED �.; Distance to nearest: Well , t.jon Property Line { b r SEEPAGE PITS �I$ "Depth::^ Size Number ! ! SUMPS ' �j Distance to nearest: Well + `' Foundation .� Property Line I DISPOSAL PONDS ❑ q i I hereby certify that Il have prepared this application and that the work will be done in accordance with San Joaquincounty ordinances, state laws,` and rules-and regulations of the San Joaquin Local Health District. y,�`° 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 asrtoTUecome subjecttto'workman,�-,compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfdrmance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws'of California." The applican s 11 r a 1 r ui�od,�inspectioomplete drawing n reverse +side.Signed`X T itle: Date:USE ONLY Application Accepted by Area �� ❑ Stk 466-6781 . ?,=:Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by w Date ❑ Manteca 823-7104: ? 2 y 4 " Final Inspection by e Date ? 'y' ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 p/ =BASE AMOUNT DUE AMOUNT REMITTE➢ RECEIVED 8Y DATE PERMIT N0. 1 10/82 500 1 EH 13-24 REV. 10/82 ' 14-26