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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781V 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 t 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 Subdivision Name r 512( t dS Owner's Name Address Ss f.� �/ (Phone o Contractor's Name *• � �S License No. �/� Phone 'K ' ��/ _ A^n r�` TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ V� PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS „',j-,INTENDED USE- - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ` - ❑ Open Bottom E]Manteca Dia.' of Well Excavation 11 &,mestic!'Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing jJ hrrigation"'- L60_ Approz. [] Eastern Specifications ❑ Cathodic Protection Depth; Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Type of Pump S V Q H.P'. " State Work Done . r• Well Destruction jJ Well Diameter $ Sealing Material (top 50') Depth 5Q Filler Material (Below 501) TYPE IOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) + Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal j SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ { LEACHING LINE Lj No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �1 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 issugd, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's, h,i,t$i!ng-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 all .required inspections. Complete drawing on reverse side. r� p� Signed X Title: �+t� Date: �p J`93 !/�� EP NT USE ONLY App ,cation Accepted b ,Cl. Rrea�� __ �Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by,4 Date ❑ Manteca 823-7104 Final Inspection by Date 0 /�/� � Tracy835-6385- Return all co ies o. Environmental Health Permit/Services 16 1 . H zeltP.O. Box 2009, Stk., CA 95201 ApplicantP FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. rNFo i3-- )7S EH 13-24 REV. 10/82 10182 500 14-26 K '