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# } f APPLICATION FOR PERMIT 1 SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT N0.0-75 Telephone (209) 466-6781 p DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED j (Complete in Triplicate) �. . Application is hereby made,to the San'Joaquin Local Health District for 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 I and the Rules and Regulations of the San Joaquin Local Health District. 19s- Job Address Subdivision Name Owner's Name L Address Phone .2 Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ W�: PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE~ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " UN IF Industrial U Open Bottom Manteca Dia, of Well Excavation _ ❑ domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing r Public Other ea xp ❑ Pbli ❑ hDlt ❑ Type of Casing [j irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout seal Geophysical Type of Grout R LJ Other 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 Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION r?r (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) - installation will serve: Residence _ Commercial Other Number of living units: _1-_ Number of bedrooms — Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines `70 Total length/size ^ FILTER BED ❑ Distance to nearest: WeiI // f Foundation too/ Property Line SEEPAGE PITS Depth Size Number SUMPS L 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ + w� 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 Loca-1,,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." � l 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 shalle y persons subject to workman's compensation laws of California." , The applicant ust call for al ire insp ctions. Complete drawing on revelse side. _ a Signed X Title: / i An/i �o r-4 Date: FOR DE RRTM£NT USE ONLY ��--`� ❑ Stk 466-6781 Application Accepted by4 Area ,__ Additional Comments: ,.[� Lan 369-3121 y-. Pit or Grout Inspection by Date Manteca'823-7104 Final Inspection by �.lthPermit/Slry Date 4,1 \— ? L Tracy 835-63$5 Applicant - Return all copies to: Environmenices 1601 E. Hazelton Rve., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE,, AMOUNT REMITTED --f')R'ECEIVED BY DATE PERMIT N0. INFO + 10/82 500 EH 13-24 REV. 10/82 14-26 �"""S