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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ��v �/ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. / Telephone (209) 466-6781 !� Q (! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I PATE 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 ,fof/f the San Joaquin Local Health District. Job Address t)4 /-il/(/ /,—Q . Subdivision Name Owner's Name �E Address ,96 4_ / 7, / Phone Contractor's Name License No. 'A- Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ OQ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well'Casing y. ❑ Public ❑Other ❑ Delta Type of Casing ❑ Irrigation Approx. [] Eastern Specifications Cathodic Protection Depth ❑ PtiDepth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [1 Well Diameter Sealing,Material (top 50') _ Depth i 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 X Commercial — Other Number of living units: -,Z— Number of bedrooms 4 Lot size 4c[J { Character of soil to a depth of 3 feet: Ss'e"'bWater table depth IC? SEPTIC TANK I ❑ 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 [❑ No. & Length of lines /V 70 Total length/size / FILTER BED x Distance to nearest-. "Well ��f_ Foundation /O Property Line r SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done it 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 sued, I shall employ erson subject to workman's compensation laws of California." The applic call for 11 re d spect'ons. Comple a on reverse side. Sr-- Signed X Title: ��t�J C��.� Date. F D P A2TMENT ONLY ❑ Application Accepted Area -�-- Stk 466-6781 Additional Comments: ❑ Lodi •369-3621 Pit or Grout Inspection by r. Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE BASE RMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT Eq Q PERMIT NO. INFO l �� (0 93 U 3-5�� lel _ 10/82 500 Eh 13-24 REV. 10/82 " } 14-26