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APPLICATION FOR PERMIT b C SAN JOAQUIN LOCAL HEALTH DISTRICT {�^� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. d d~ 0 Telephone (209) 466-6781 - } DATE I55UED��, PERMIT EXPIRES I YEAR FROM DATE ISSUED TT (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workhereint 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 ulions of the San Joaquin Local Health District. Job Address K 0Subdivision Name Owner's Name ] 1 Q Address Phone License No. Phone Contractor's Name L +^} TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C: FOUNDATION•- --- - -.AGRICULTURE-WELL "—OTHER-WELL""" ----PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑'ri Delta �(�-— ❑- Type of Cas i ng- - U Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ;f Geophysical ` 17Type of Grout ❑OtherSurface Seal Installed by Repair Work Done [JType of Pump H.P. State Work Done ----------- Well Destruction ❑ Well Diameter Sealing Material (top'50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) -� Installation will serve: Residence Commercial Other ( �1 Number of living units: Number of bedrooms Lot size x_ciD Character of soil to a depth of 3 feet: Water table 4th SEPTIC TANK Type/Mfg Cmw E_ _ _ Capacity ��}� _ No. Compartments i PKG. TREATMENT PLT. ❑ Type/Mfg. Capacity Method of Disposal I Septic Tank E, Distance to nearest: -Well Foundation Property Line 1 Destruction LEACHING LINE No. & Length of lines Total length/sized +-f FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ Depth Size 3 X Number SUMPS LJ Distance to.nearest: Well Foundation Property Line c 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 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 wo`rkmans 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 thi mit is issu�, Iall ploy persons subject to workman's compensation laws of,California." The applic s 1 eqed pections. Complete d�ng on everse side Signe Title: Date:' WD g ' Application Accepted by R D ARTMENT_U5E ONLY Area D� �] Stk 466-6781 Additional Comments: / - [] Lodi 369-3621 Pit or Grout Inspection byDate '1�` Manteca 823-7104 Final Inspection by I Date la' �Z ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Service 1601 E. Hazelton Ave., P.O. Box 2069, Stk., CA 95201 rEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. FO - k EH 13-24 REV. 10/82 Y 10/82 500 14-26