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APPLICATION FORPERMiT SAN JOAQbiN LOCAL H_.ALTH 01 T 1601 E. HAZELTON AVE., STOCKTON, CA SEP 2 6 1983 PERMIT NO. d(o L! Telephone (209) 466-5782 I PERMIT EXPIRES I YEAR FROM GATE I l� a" 3yN) LMAL DATE ISSUED �3 (Complete in Triplicate) HEALTH DISTR2CT 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 San Joaquin Local Health District. Job Address `� r bdivision Name Owner's Name Address Phone Contractor's Name License No. Phone f TYPE OF WELL/PUMP WORK: . NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial ❑ Open Bottom [] Manteca Dia, of Well Excavation @El"Domestic/Private Gravel PackTrac ❑ Y Dia, of Well Casing ❑ Public ❑ Other ❑ Delta irrigation Type of Casing ❑ Specifications C h Ap ❑ Eastern 5 ecifications Cathodic Protection Depth P , ❑Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by y , Repair Work Done Type of Pump . y H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITI'ON ❑ (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 I Character of soil to a depth of 3 feet: Water table depthy SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal ~~~ SEWAGE SYSTEM Distance to nearest: Well, Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line V SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation. Property Line DISPOSAL PONDS ❑I I 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." 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 call f all required inspections. Complete drawing n reverse side. Signed X Title: } Date: DEP,(4RT T U$E ONLY Application Accepted by Area Stk 465-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by � Date '�;� Tracy 835-6385 Applicant - Return all copies to: Environmertal Health 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 q 14-26