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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT q -7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a f '1- 3 Telephone (20 9) 466-6781 } \� DATE ISSUED 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 workherein' 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 Sa Joaquin ocal Health District. Job Address i division Name ; Owner's Na _Address Phone Contractor's .Nam License No. Phone 163bl-5,10- TYPE •s'0G-TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT [] DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER 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 Dol Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/P•rivate w ❑Gravel Pack ❑Tracy Dia. of Well Casing Public Other Delta ❑ C1 ❑ Type of Casing f] irrigation Approx. ❑Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal.installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ] Well Diameter Sealing Material (top 50') `F Depth Filler/ aterial (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR%ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is ��. available within 200 fee_t.) Installation will serve: Residence �� Commsercial �}j Oth�er¢� Number of living units: r Number of. b dr_.00ms' 'Lot size /0 Cte,,Za.,@� Character of soil to a depth of 3 feet.:.,.' rr _ Water table depth SEPTIC TANK Type/Mfg - .: _,Capacity 1:200 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg =`4i� 1 Capacity Method of Disposal Distance to nearest: Well" }Foundation,"""""/0 Property Line LEACHING LINE No. & Length of lines 3 Total length/size Ir 2 FILTER BED [] Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS Depth Size _{ Number` SUMPS ❑ Distance to nearest: WellFoundation Property Line - � f DISPOSAL PONDS ❑ / °` ` I hereby certify that 1 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.,tubject to workman K 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 applic t must c fo all required inspections. Complete drawing o w everse side. �f ` �'] Signed X Title: Date: "s c DE � . Appl tion Accepted by I Jefr FOR MENT`�>�S � ONLY Area � � Stk 466-6781 � - Additional Comments: Lodi 369-3621 ,. Pit•or Grout Inspection _ Date Manteca 823-7104 Final Inspection by' Date 1 PL Tracy 835-6385 Applicant - Return all.copi t . Envi onmen 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 1 DATE r� PERMIT NO. INFO A !�' }toO ' ZZ EH 13-24 REV. 10/82 10/82 500 14-26