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r APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781. • DATE ISSUED E 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 S Joaquin Local Health District. Job Address s Subdivision Name Owner's Name Address Phone Contractor's Name I License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER U 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 r iBottomU Open Manteca Dia, of Well Excavation 4 omestic/Private ravel, Pack racy Dia. of Well Casing Public Other Delta Type of Casing Irrigation Approx. [] Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical E Type of Grout [ O LJ Other Surface Seal Installed by Repair Work Dane G Type of Pump H.P. State Work Done A Well Destruction F-1 Well Diameter�� Sealing Material (top 5O') Depth I� Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) •�� Installation will serve: Residence — Commercial _ Other 09 Number of living units: Number of bedrooms Lot size A Character of soil to a depth of 3 feet: Water table depth rl� SEPTIC TANK Cj Type/Mfg . Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of-lines Total length/size .F FILTER BED Distance Lto nearest: Well Foundation Property Line V SEEPAGE PITS ❑ Depth I Size Number SUMPS U 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 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 i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant call f all a ired inspections. Complete drawing on reverse side. Siqned X Title: Date: F0 RTMENT USE ONLY 9 7 E] Stk 466-6781 ` Application Accepted by � Area __�� , Additional Comments: Lodi 369-3621 Pit or Grout 'Inspecti n by Date Manteca 823-7104 men by , pate Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, St k., CA 95201 „ =� BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. q Xn, 10/82 500 i EH 13-24 REV. 10/82 14-26