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r • APPLICATION FOR PERMIT 4 SAN JCAQLi`: LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I 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 CJS and the Rules rd Re latio of t an oa�uin Local Health District. V Job Address Subdivision Name Owner's Name Address Phone �— Contractor's Name �)") �® License No. ell 91 L_-j4 3 6 7 Phone p TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i❑'Industrial U Open Bottom ❑Manteca Dia. of Well Excavation 0 Domestic/Private ❑ Gravel Pack ❑ Tracy -9ia.' of Well Casing (] Public ❑Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Depth Depth of Grout Seal ❑Geophysical Type of Groot ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction F-1 -.Well Diameter Sealing Material (top 50') t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK:, NEW INSTALLATION LI REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is 0 " 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 [j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg J Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well undation Property Line DESTRUCTION �� ffLL LEACHING LINE No, ,& Length of lines 1 Total length/size F FILTER BED ❑ -Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size �3 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 permit is issued, I shall not employ any person in such manner as to became subject to workmant compensation Taws 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 applicantu all for all fired inspect' S. Complete d awing on reverse side. Signed X Ti le: Date: NT ONLY Application Accepted y Area _�_ E:] Stk 466-6781 Additional Comments [� Lodi 369-362 Pit g*:£ereut Inspection by Date alb-3 L] Manteca 823-7104 Date !::2 A— Tracy 835-6385 Final inspection by �� L ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 i`U