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i i APPLICATION FOR,PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. IN- 630 Telephone (209) 456-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ; Application is hereby made to the San Joaquin Local Health District for a permit'tc 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 Ruless-and Regulations of e J quin Local ealth District. Job Address Subdivision Name 1 Owner's Nam � Address 'Phone Contractor's Name License No. ZZ 7 21Phone, TYPE OF WELL/PUMP WORK: NEW WELL �] WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ .'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS SIJ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1❑ Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing17 { Public CJ Other ❑ Delta Type of Casing (,�} Irrigation t !—i 9 Approx. ❑ Eastern Specifications ❑ Cathodic Protection' Depth r„ ❑ Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by (� Repair Work'Done'o Type°of-Pump-- - H:P:- - » _- -State-Work Done-- Well Destruction ❑ Well Diameter Sealing Material (top 50`) Depth Filler Material (Below 50') E TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ ;(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: Number of bedroom Lot size r r Character of sail to a depth of 3 feet: Water table depth_,:_ SEPTIC TANK {/ Type/Mfg opacity "No: Compartments 4 :', PKC. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGESSYSTEM ON ❑ Distance to nearest: Well Foundation Property Line �jr DI L LEACHING LINE No. & Length of lines �. Total length/size p FILTER BED ❑ Distance to nearest: Well /Foundation Property Line 1 SEEPAGE PITS Depth Size �Z? ac r Number , SUMPS L-1 Distance to nearest: Well �e Foundation Property Line i-DISPOSAL PONDS t K.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 workman compensation Paws 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 must c it for all re ui;pd inspec ons. Complete drawineverse s-de. _ * Signed X * + Title: Date- '00, y� l I F PARTMENT USE ONLY F Application Accepted by Area ate-- Stk 466-6781 Addi•ttional Comments: ❑ �•m OQQ � Lodi 369-3621 it or Grout Inspection by Date ❑ Manteca 823-7104 #w Final Inspection by Date ^ ❑ Tracy 835-6385 Applicant - Return all cop es o: Environmental Health Permit/Services 1601 E. Hazelton P.D. Box 2009, Stk., CA 95201 FEL BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �- S-7.J-Q1� -1,030 t . EH 13-24 REV. 10/82 10/82 500 14-26