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APPLICATION FOR PER`'!T SG.N JOAQUiN LOCA: HEALTH DISTRICT 1601 F. HA7ELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO, DATE ISSUED J(w Application is hereby made to the San 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 the San Joaquin Local Health District. Job Address fd -rA L,/ Subdivision Name Owner's Name Address Phone Contractor's Name License No, �Qr _ Phone g[� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION �f PUMP INSTALLATION SYSTEM REPAIR L7 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE Industrial Lj 0omestic/Private ❑ Public 71 Irrigation FI Cathodic Protection ❑ Geophysical ❑ Other Repair Work Done ❑ Well Destruction Lf TYPE OF WELL U Open Bottom ❑ Gravel Pack F-1Other Approx. Depth Type of Pump Well Diameter Depth PRnRI FM LPFL U Manteca ❑ Tracy Del to Eastern H. P. Sealing Material Filler Material CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation " Dia. of Well Casing Type of Casing Specifications Depth of Grout Seal Type of Grout Surface Seal Installed by State Work Done (top 50') (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION X (No septic tank or seepage pit permitted if public sewer is / available within 200 feet.) Installatlon will serve: Residence ./ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK 0 Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg SEWAGE SYSTEMDistance to nearest: Well DESTRUCTION ❑ Lot size Capacity Capacity Foundation _ Water table depth No. Compartments Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth / -;,- f Size X .0 Number f 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 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 it is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." Cont tor's hiring or sub -contracting signature certifies the following: "I certify that, in the performance of the work for which this per is issuedLIThall mploy persons subject to workman's compensation laws of California." T plic t car 1 eq i ed pections. Complete wing on rev, Signe - A—M 44 Title: Date: r � .--�A' OR PA Title: USE ONLY ]meq Application Accepted by /v(?s`-' Area 7 (L�,fP4C I Stk 466-6781 Additional Comments: f'l II�J Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by �� , L_ Date..7/ -44_E L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFD -4 EH 13-24 REV. 10/82 10/82 500 14-26 ck2a#' CA 0�