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APPLICATION FCR PERMIT SAN JOAQU;N LOCAL HEALTH DISTRICT C`3 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ✓SD Telephone (209) 456-6781 DATE ISSUED go 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 Rule and Regulations of, thblSan Joaquin Local Health District. Job Address _ Subdivisi ame . o Owner's Name Address - Phone No. Phone Contractor's e Name ? s 1 TYPE OF WELL/PUMP WORK: NEW TELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ r,Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF', WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I {F1 Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation r,, ❑ Domestic/.Private Gravel Pack Tracy Dia. of Well Casing ll" Public Other Delta ' ❑ Type of Casing ❑ Approx. EasternIrrigationDepth Specifications Grout .Cathodic Protection Seal_ Geophysical j •.y� "� �{ - Type of Grout ° j J Other s Surface Seal Installed by 1 _State..Work_Done ,T-- Repair Work Done ❑ Type of Pump H_ P•.,. r - -- Well Destruction ❑ Well Diameter C Sealing Material (top 50') Filler Material (Below 50') DepthO-_ , Y a TYPE OF SEPTIC WORK: NEW INSTALLATION =1REPAIR/ADDITION E) (No septic tank or seepage pit permitted if public sewer is 11 available within 200 feet.) installation will serve: Reside ce Commercial Other Number of living units: ;Number of bedrooms Lot size fJ Water table depth Character of soil to a depth of l3 feet: I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal I, SEWAGE SYSTEM � Qistanceito nearest: Well Foundation Property Lin# cls DESTRUCTION LEACHING LINE ❑ No. & Lehgth of lines Total length/size k FILTER BED ❑ Distance1.to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth .f Size Number SUMPS Lr1 Distancel to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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 st call orIall re uir'2d inspections. Complete drawing on reverse side. Title: Date: p Signed X , . �AAFO EPARTMENT USE ONLY � "7 Stk 466-6781 Applicati n Accepted by Area Lodi 369-3621 1 Additional Comments: ❑ Manteca 823-7104 f Pit or Grout Inspection by Date Final Inspection bye _ Date b--�� I'� ❑ Tracy 835-6385 Applicant - Return all copies to: Environ al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 DATE PERMIT NO. FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY _23 7� INFO 6!Q✓ 10/82 500 EH 13-24 REV. 10/82 14-26