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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON .AVE., STOCKTON, CA PERMIT NO. g - /0/OW Telephone (209) 466-6781 �pp DATE ISSUED Y' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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 S r Joaquin Local Health District. Job Address /y Subdivision Name Owner's Name Address Phone Contractor's Name a License No, 7 Phone _Q TYPE OF WELL/PUMP WORK: NEW WELL �( WELL REPLACEMENTDESTRUCTION U 2 c_S i PUMP INSTALLATION SYSTEM REPAIR - OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE _ Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private P5.11ravel Pack Tracy Dia. of Well Casing �] Public [—I Other Delta Type of Casing LjIrrigation Approx. ❑ Eastern Cathodic Protection Depth Specifications �d Q Geophysical Depth of Grout Seal ` [f * Type of Grout Other t,qr Surface Seal Installed by Repair Work Done [ Type of Pump H.P. _3 State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil 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 , I SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ E LEACHING LINE LJNo. & Length of lines Total length/size 11 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth Size Number 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 permit is issued, I shall not employ any person in such manner as to become subject to workman5 compensation laws of California." y 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 mus 1 for 11 requi i ections. Complete drawl on reverse side. Signed X Title: +�pj� y Date: i. F DEPARTMENT SE ONLYQ�` ,�C/�p Application A epted by v Ap'ea /C/ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspectio Date AU-10 D Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all cop s Environmental Health Permit/Services 16 .1 E. azeltAve_ P,O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO f EH 13-24 REV. 10/82 y 10/82 500 14-26 ` it