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4 w APPLICATION FOR PERMIT ' y SAN JOAQLiN LOCAL HEALTH DISTRICT .p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 Z DATE ISSUED J 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 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 J .1 t �t & '`A& cion Name Owner's Name �i lIITTT Address 2 Contractor's Name Z License No. e-3 JuZ. Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ �v�V 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 I❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation — iDomestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Inst led by Repair Work Done ❑ Type of Pump H.P. 1 State Work Done Atj1_-Y2_ L Well Destruction F-1WellDiameter Sealing Material (top 50') N Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is O available within 200 feet.) O 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 L' 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 ❑ ^ LEACHING LINE j❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ L 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§ 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 applicant must call for a required inspections. Complete dr ing on reverse side. Signed X Title: Dater DEPARTMEN ONL Stk 466-6781 Application Accepted by Area _ 13 Additional Comments: E] Lodi 369-3621 >v ! Pit or Grout Inspection by Date %e Manteca 823-7104 Final Inspection by ' '� ��`�-� Date ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Il- 343- rit FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE Q PERMIT NQ. 7� v a—W INFO d EH 13-24 REV. 10/82 10/82 500 14-26