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APPLICATIOWFOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �! i Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED (p (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 and the Rules and Regulations of th6,San Joaquin Local Health District. Job Address _ _ Subdivision Name Owner's Name ``" ``" Address Phone Contractor's Name • License No: Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT�11❑• DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER EJW DISTANCE TO NEAREST: SEPTIC .TANK. _ _ SEWER LINES-, -DISPOSAL-FLD--- PROP. LINE ' ` FOUNDATION AGRICULTURE WELL t OTHER'WELL PITS/SUMPS ��1-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ DDmestic/Private ❑Gravel PackTrac ❑ Y Dia. of Well Casing ❑ Public ❑Other ❑ Delta Irrigation Type of Casing Approx. ❑ Eastern ❑Cathodic Protection . Depth Specifications Ej Geophysical Depth of arout Seal Other Type,of Grout Surface Seal Installed by -- .Repair Work Done ❑. Type of Pump H.P. State Work Done �► Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth _ Filler Material: Below 50'} d v 11 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (� ❑ � (No septic tank or seepage pit permitted if pub1ic'sewer is ``•,� ° available within 200' feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size f Character of soil to a depth of 3 feet: ' f p [ Water table depth- SEPTIC TANK ❑ Type/Mfgacit Ca • p Y fio_yCompartm��s•._, � .•W„ � PKG. TREATMENT PLT: ❑ Type/Mfg ;' Capacity, Method of Ofsposal Distance to nearest: Wel 1, Foundation i Property e G p Y Linn 4 (Q, LEACHING LINE No. & Length of lines _ Total length/size, FILTER BED E] Distance to nearest: Well :: Foundation , Property Line SEEPAGE PITS _ [] Depth Size� Humber SUMPS ❑ Distance to nearest: Well j Foundation Property,L•ine -'; DISPOSAL PONDS ❑ r- 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:_"1,certi,fy th`'at in the performance of the work for which this permit is issued. I shall not employ any person in such man6er'as td become subject-to workmant compensation laws of California." { Contractor's hiring or sub-contracting signature certifies the following "I certify th'at ,M '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 for all required inspections. Complete drawing on reverse side, i Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by .' 'r,I; ` Area E] Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by �, , Al Date ' � _ � Tracy 835-6385 Applicant - Return all copies tOYL-EnMnme . Health Permit/Services 1 f Fla n Ave., P..O. Box 2009, Stk., CA 95201 .y FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVES BY DATE - PERMIT NO. INFO 3 4Z EH 13-24 REV. 10/82 { 3 14-26 10/82 500 p �f