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APPLICATION FOR PERMIT SAN ,IOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � 0� Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED GATE ISSUED (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 well/pump and the Rules and Regul tions of the San Joaquin Local Health District. Job Address 1p �/ a Subdivision Name Owner's Name Address Phone - Contractor's Name License No, Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION. SYSTEM-REPAIR OTHER-U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial _ 0 Bottom L.J en P E] Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel PackTrac ❑ Y Dia. of Well Casing Public �jOther Delta LjIrrigation Type of Casing Approx. � Eastern Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done FJ_ Type of Pump H.P. State Work Dane Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK; NEW_INSj2LLATION *-I REP 4IR/A9DiTTDtY "j No SeFrtic Jan or'seepage p9't pe"mitted if public sewer is Installation will serve: Residence Commercial _ Other available within 204 feet.) 4 Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: _ Water table depth4l SEPTIC TANK Type/Mfg Qs7 ho tv . _ '- Capacity �Ori No. Compartments PKG. TREATMENT PLT. 7 e Mf ❑ YP / 9, Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line /19 DESTRUCTION ❑ -a�� LEACHING LINE No. & Length of lines ' [_ ",4u}Total length/size- FILTER BED Distance to nearest: Well nr� Foundation 1 ltd Property Line N _ SEEPAGE PITS L Depth Size _ Number SUMPS Distance to n rest: Well Foundation ! _ Property Line `fes=` 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 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 n1-1 f or I requir i ns. Complete drawing on reverse side. Signed X77.0 _ Title: __ Date: C Application Accepted by ru Er' TENT USE ONLY(� Area Stk 466-6781 Additional Comments: � Lodi 369-3621 Pit or Grout Inspection by Date Manteca' 823-7104 Final Inspection by Date Tracy C 835-6385 Applicant - Return a17 copies to: YTionm�ental h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 _