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APPLICATION FOR PERMIT ' SAN JDAQUif; LOCAL HEALTH DISTRICT � — 1601 E. HAZELTON AVE., STOCKTON, CA 6 PERh11T NO, g3� Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED Pd- e6eP G DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal] 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 Rejulations of th S�Joa Local He District. Job Address U �V• ubdivision Nam Owner's Name Address Phone Contractor's Na License No. Phone r TYPE OF WELL/PUMP WORK: NEw WELL WELL REPLACEMENT DESTRUCTION L PUMP INSTALLATION Q SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE \\, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing 17 Public 7Other Delta V Irrigation Approx. Eastern Type of Casing Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical U Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OFrSEPTIO WORK: NEW INSTALLATION REPAIR/ADDITION D (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: Numbef�of be ooms L size _ �(Le Character of soil to a epth of 3 et�_ r Water table depth SEPTIC TANK [r Type/Mfg t 'GC Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: -Wel] SQ.__._.Foundation /D � Property Line X� DESTRUCTION LEACHING LINE No. & Length of lines _ y/� Total length/size FILTER BED Distance to nearest: Well 1,�&' Foundation Property Line 15____ SEEPAGE PITS Or. Depth Size3 3 i Number z SUMPS Distance to nearest: Well Foundation /Q _ _ 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 workmanis 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant m t call for a required inspections. Complete drawing or rve side. Signed X t _ Title: �/, / Date a, Aa�ww,, F PARTMENT USE ON -],X y0+QApplica ' n Accepted by� Area Stk 466-6781 I {Q7�� Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by - Tracy 835-6385 _ Date s -� ❑ Applicant - Return all copies to: Environmen Health Permit/Services 1 01 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO t � r 8'L3- EH 13-24 REV. 10/82 10/82 500 14-26