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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3- 1A Telephone (209) 466-6781 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 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/A � AAjoit Ed division Name Owner's Name . f Address—� hone Contractor's ef License No Te . Phone _p 0 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing _v ❑ Public ❑Other ❑ Delta Type of Casing _411 W Irrigation Approx. [:] Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other t Surface Seal Installed by Repair Work Done ❑ Type of Pump lit. H.P. l State Work Done Well Destruction [—IWell Diameter ri Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF 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 4� Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ci Distance to nearest: Well Foundation Property Line DESTRUCTION CA LEACHING LINE ❑ 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 CI 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 4 permit is issued, I shall not employ any person in such manner as to become subject to workmant 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 applic�an�t mus carr all required inspections. Complete drVingreverse side. IAIA- Signed X 41 .Y4, ( /�1-A—� --- Title: '" Date: —F W V FO TMENT�USE ONLY Stk 466-6781 Application Accepted by ��_ CAi1 �' Area l� ❑ Additional Comments: [� Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Dated--Zf ? ❑ Tracy 835-6385 Applicant - Return all copi es-Yo: Environmental Health Permit/Services 1601 E. Hazelton AvA., P.O. Box 2009, Stk., CA 95201 UFEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. 10/82 500 EH 13-24 REV. 10/82 _� U 14-26