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APPLICATION FOR PERMIT g � / �J J SAN JOAQUiN LOCAL HFALTH DISTRICT O / `� j �(�� 16D1 E. HAZELTDN AVE., STOCKTON, CA PERMIT N0, v � f Telephone (209) 466-6781 q v v v DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED R O D M (Complete in Triplicate) Application is here7gy made to t4e-5 n 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 and the Rules and Regulations of he San Joaqui oval Health District. Job Address QQ ,Q� Gdrr-Heave Owner's NameAddress Phone 7 Contractor's Name License No. .S� Phone TYPE OF WELL/PUMP WORK: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION g. SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a)� ❑ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation X Domestic/Private Gravel Pack_ -__DTracy Dia, of Well Casing ❑ Public ❑Other Delta T Irri anon- -... Type of Casing �i g J� Approx. ❑ Eastern- _. ❑Cathodic Protection Depth Specifications ❑Geophysical 1 1 � Depth of Grout Seal ! Other I 0 Type of Grout &—,—e r,J Surface Seal Installed byQrj�. Repair Work Done [J Type of Pump H.P. State Work Done a Well Destruction ❑ Well Diameter 6" Sealing Material (top 50') Depth Filler Material (Below 50') f., TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is VV available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Lot size Character of sail 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 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Ll 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 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 workmanl; 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 issu , I shall employ persons subject to workman's compensation laws of California." The applicant must c or a 1 r ired inspections. Complete drawing reverse side.. Signed X Title: T Date: ,f OR DEPA ENT ZUSE Y Area 466 -6781 Application Accepted by Z/ p' Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date �� LJ Manteca 823-7104 Final Inspection by Datee_'�k ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental alth Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT UE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO q - 141 EH 13-24 REV. 10/82 10/82 500 14-26