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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT k y 1601 E. NAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED S 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 i described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump E and the Rues and Regulations of he an J quip Local Health District. 4 ,ldb Address Subdivision Name Phone Owner's Name _ N Address Contractor, Name License No. Phone 's TYPE-OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r„ t DISTANCE•TO"NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE VWz i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE a. . . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Open Bottom 0 Manteca pia, of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing Publ is J ❑Other E]Del tam Type of jirrigation Approx., ' ❑ Easternf Specifications ❑Cathodic Protection Depth Depth of'Grout Seal l ❑Geophysical Type of Grout ❑Other /� Surface Seal Installed by Repair Work.Done ❑ Type of Pump H.P. State Work Done } Well Destruction ❑ Well Diameter -- Sealing-Material- (top 50') J Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation. will serve: Residence Commercial _ Other Number o.f living units: Number of dro.ms Lot size f�/_Fold.- sr0 Character of soil to a depth of 3 feet: Water table depth /,—, � A9 SEPTIC TANK ❑ Type/Mfg Capacity r No. Compartments.' PKG. TREATMENT PLT. ❑ Type/Mfg Capacity s-- Method of Disposal 4% Distance to nearest: Well Foundation Property Line {` LEACHING LINE ❑ No. & Length of lines Totalilength/size FILTER BED Distance to nearest: Well �— Foundation Property Line I SEEPAGE PITS ❑ Depth Size Humber SUMPS ❑ 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 Loca]06althDi t"rTcf'"' Home owner or licensed agent's signature certifies the following: "I certify that in the perfoi-mance of the work for which this { permit is issued, I shall not employ any person in such manner as to become subject,to workman k compensation laws of California." f Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which f this permit is issued, i shall employ persons subject to workman's compensation laws of Cali�foYnia."" The applicant must call for l re 'red inspections. Complete drawing on reverse side. i Signed X Title: 3 Date: '5 ' . .le_l- R D !{TMENT USE ONLY Application Accepted by Area Stk 466-6781 T Additional Comments: - - ❑!Lodi 369-3621 Manteca 823-7104 Pit or Grout Inspection by �:. �� - 'a\ '.Date /❑ Final Inspection by _// Date ❑ Tracy 835-6385 Applicant - Return all copies to: EnviromLintal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i G FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT t INFO $3 'S 3 10/82 500 EH 13-24 REV. 10/82 14-26