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APPLICATION FOR PERMIT J 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. f`S 0 Telephone (209) 465-6781 { DATE ISSUED X f�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1i Application is hereby made to the San Joaquin Local Health District for a permit to construct land/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 *Z 7-'%% POL `,h. Subdivision Name I Owner's Name � 7, %- Address Z.. s Phone _ Contractor's Name f2f- �_ License No. ii Phone TYPE OF WELL/PUMP WORK: NEW WELL F7 WELL REPLACEMENT DESTRUCTION Il j PUMP INSTALLATION SYSTEM REPAIR OTHER U !I f 1 DISTANCE TO NEAREST: SEPTIC TANK .. SEWER LINES DISPOSAL FLD. PROP. LINE 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial U Open Bottom Manteca Dia. of Well Excavationl! L,I Domestic/Private Gravel Pack Tracy Dia, of Well Casing ��rt Public F-1 Other Delta Type of Casing F, irrigation Approx. Eastern Specifications ❑ Cathodic Protection Depth LF1 Geophysical Depth of Grout Seal Other Type of Grout LJ Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) � } Depth Filler Material (Below 50') F' TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is ravailable within 200 feet.) Installation will serve: Residence Commercial _ Other 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 SEWAGE SYSTEM Distance to nearest: Well} Foundation Property Lina DESTRUCTION Q ' LEACHING LINE U No. & Length of lines " Total length/size d I FILTER BED Distance to nearest: Well + Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 7I I hereby certify that 1 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 workmant 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 person`s subject to workman's compensation laws of California." ' The appl ' must call fo all requi ins It' ns. Complete drawing on reverse side. Signed Xcant Title: Date: `� 0 'p F DEPARTMENT USE ONLY Application kcepted b Area _Z_ /11@2-"S"tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by _ F Date _ '" Manteca 823-7104 Final Inspection by �� _- Date 1p-_? I ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 rEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. NFO EH 13-24 REV. 10/82 / ��` 11cvti. Glp /�, 1D/82 500 14-26 I!