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i APPLICATION FOR PERMI 4 SAN JOAQU'iN LOCA'L,HEALTH DISTRICT ., J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 465-6781' DATE 155UEp PERMIT EXPIRES 1'YEAR FROM DATE ISSUED !f (Complete in Triplicate) Application is hereby made to the San Joaquin Lccal'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 far well/pump and the Rules pcL,_Regulation the n Joaquin Local Health District. Job Address 4ilf Subdivision Name Owner's Name Address Phone k Contractor's Name en se No. Phone i TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U ! PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER Wt LL PITS/SUMPS l INTENDED USE TY,E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1J Industrial U Open Bottom Manteca Dia, of Well Excavation U Domestic/Private P Gravel. Pack Tracy Dia. of Well Casing Public L Other L Delta Type of Casing I V Irrigation Approx. Eastern Specifications L Cathodic Protection Depth Depth of Grout Seal 17 Geophysical � Type of Grout LJ Other Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done i Well Destruction U Well Diameterl Sealing Material (top 50') — pJ Depth Filler Material (Below 50') O TYPE OF SEPTIC WORK:. 'NEW'INSTALLATION L REPAIR/,ADDITION UfI (No septic tank or seepage pit permitted if public sewer is ,�. available within 200 feet..) Installation will serve: Residence ommercial Other w* D Number of living units: _j_— Number of bedrooms c Lot size Character of soil to a depth of 3�feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to,nearest: Well at ionProperty Line DESTRUCTION I! LEACHING LINE L ' No. & Length of lines Total length/size !U FILTER BED Distarce.to nearest: Well Foundation Property Line SEEPAGE PITS L Qepth ize Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j 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 t 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 i this permit is issued, I shall empI ersons subject to workman's compensation laws of California." The applicY u 1 f all re' red inspection mplete&drwing on reverse si4de. y � itle: Date: Signed X - I F D P RTME T USE ONLY Application Accepted by Area Stk 466-6781 Lodi 369-3621 Additional Comments: ❑ Date ` Manteca 823-7104 Pit or Grout Inspe ion by ' � final inspection by Date l�1-S= 'j Tracy 835-6385 Applicant —Return all co ' s o: I Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 DATE PERMIT NO. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY Y O l 1 10/82 500 EH 13-24 REV. 10/82 t' 14-26