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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON —7!j--70(5 AVE., STOCKTON, CA PERMIT NO. 6!--7qs Telephone (209) 466-6781 DATE ISSUED \9 F PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) 1 Application is hereby made.to the San JoaquirdLocal Health District for a permit to construct and/or install the work herein described. This application is made in compli'Ahce with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio of the San Joa.qudn Local Health District. Job Address :, Subdivision Name i Owner's Name Address Phone Contractor's a Phone License No. 3 �y f TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION F PUMP INSTALLATION SYSTEM REPRIR OTHER LI DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS llll! ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack F] Tracy Dia. of Well Casing i Public Other Delta Type of Casing E— i'Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth Depth of Grout Seal E,GeophyYi'cal f Type of Grout B . I--]Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done N Well Destruction U Well Diameter Sealing Material (top 50') - Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Lf REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is / available within 200 feet.) Installation will serve: Residence r Commercial _ Other , Number of living units: N'Umber-o'f-b-6-dr`ooms YrLot size Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Type/Mfg Capacity. Method of Disposal ' SEWAGE SYSTEM Distance to n2arest`:� Well Foundation— g, Property Line DESTRUCTION ❑ IL LEACHING LINE L� No. &'Le -of lines -_ Total length/size FILTER BED a Distance to earest:—Well Foundation Property Line - SEEPAGE PITS Depth Size " Number T l SUMPS U Distance to'nearest: Well _!o Foundation q }- Property Line DISPOSAL PONDS ED ----� r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county i 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, 1 shall employ person s:.subject to workman's compensation laws of California." The applicant must call forallr uired inspections. Complete drawing on reverse side. 444 Signed X i7`+ Title: Date: FO DEPARTMENT USE ONLY �' 466-fi7B1 Application Accepted by Area l JStk Additional Comments: Ej Lodi 369-3621 Pit or Grout inspectionAb Date Manteca 823-710Final Inspection:by Date ❑ .Tracy 835-6385 Applicant - Return all copies vironmental Health Permit/Services 1601 Ha elton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. *� i INFO ;'tis-, -79s� 10/82 500 EH 13-24 REV. 10/82 14-26