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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED p2 (Complete in'Triplicate) 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 and the Rules and Regulations of the San oaquin Local Health District. well/pump Job Address s Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW�WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ o�j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation ❑ Domestic/private ❑Gravel ,Pack i ❑ Trac Y Dia, of Well Casing, ❑ Public ❑Other' ❑ Delta! F1 Irrigation Approx. ❑Eastern Type of Casing ` ❑Cathodic Protection Depth Specifications Ej Geophysical E Depth of Grout Seal ❑Other Type of Grout Surface Seal.Installed by Repair Work Dane F1Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter C Sealing Material (top 501) 0, Depth { Filler Material (Below 501) I' rf TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is a1 Installation will serve: Residence Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size � 76, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity P Y No. Compartments Aw PKG, TREATMENT PLT. ❑ Type/Mfg : Capacitye Method. of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines er' Total length/sizer FILT€R BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth w 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 employtany person in such manner as to become subject to workman.% 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 mus call for all r uired 'nspections. Complete drawing o r verse ide. Signed X Title: &AntDate: _ DE TMENT E ONLY ^ Application Accepted b Area _ O�tk 466-6781 Additional Comments: ❑ Lodi 369-362.1 Pit or Grout Inspection by DW Date °ate ❑ Manteca 823-7104 Final Inspection by Date — 05 Tracy 835-6385F Applicant - Return all copies Fri ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO PERMIT N0.( E y :3 EH 13-24 r REV. 10/82 14-26 10/82 5O r '