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t I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3'3 44 Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED a (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 f and the Rules and Regulati of the San Joaquin Local Health District. Jab Address Subdivision Name Owner's Name Address phone Contractor's ' License No. Phone 1 TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER [� w DISTANCE TO NEAREST: SEPTIC TANKry.1 SEWER LINES DISP05AL FLD. PROP. LINE W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v" INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION SPECIFICATIONS ' 17 Industria] U Open Bottom ❑Manteca Dia. of Wel] Excavation jJ Domestic/Private ,�❑ Gravel Pack Trac # ❑ P�Iblic ❑ Y Dia. of Wel] Casing � I Other ❑ Delta j] 1lrigation Approx. ❑ Eastern Type of Casing m + ❑Cathodic Protection Depth "1Specifications j Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) ) Depth Filler Materiel .(Below_50 }Y-� TYPE OF SEPTIC WORK: NEW INSTALLATION �j REPAI DD TION — (No a is tank or seepage pit permitted if public sewer is insltallation will serve: Residence Commercial Other available within 200 feet.) Number of riving units: Number of bedrooms Lot size , Character of soil to a depth of 3 fe t: i - Water table depth Q p SEPTIC TANK Type/Mfg _ &2LP _ y ab T � _ _ !� d Capacity Z�.C, No. Compartments PKG. REATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ` Distance to nearest: Well —9Q0 --F0 /iFJ ,� property Line LEACHING LINE Nod & Length of lines f ------- Tota] length/s"ize / FILTER BED �w. Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth 4' Size " Number - SUMPS jJ 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,D.istriet. Home owner or elicensed, I' ha4all t5s signature certifies the following: "I. certify that'in.the performance of the work for which this a permit is issued, f shall not�jemploy any person in such manner as to become subject to'workmanK compensation laws of California." „ Contractor's hiring or suli-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 apRlicant ust call for all r ired inspe tions. Complete dra g on reverse side. Signed X Title: � Cate: _ DEP T U E ONLY Application Accepted by Area i� � 5tk 466-6781 Additional Comments: f �`�' ❑ Lodi 369-3621 Pit or Grout Inspection by 71D)ate /7c ❑ Manteca 823-7104Final Inspection by ' Tracy 835-6385 Applic nt - Return all copies:to: Environmental Health_Permi.t/Ser6 E. Hazelton Ave., P.C. Box 2009, Stk., CA 95201 J FEE BASE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. EH 13-24 REV, 10/82 14-26 10/82 500