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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO., Telephone (209) 466-6781. OATS i5SUE0 P€RMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein described. This application:l,is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump and the Rules and Reg ul„aons I of.the San Joaquin-Loc 1 Health District. f Job Address �f/ �I� w ' 1�� Subdi isian Na tme i Owner's NameA dress �+ Phpne 3 Contractor's Name ilkl b License No. Phone TYPE OF WELL/PUMP WORK: I� NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC;��. SEWER LINES DISPOSAL FLO. PROP. LINE Tom— ---r_ FOUNDATkON AGRICULTURE-WELL- OTHER WELL PIT5/SUMP$ _ INTENDED USE I!TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1IndustrialI] Open Bottom❑ Manteca Dia. of Well Excavation ❑ IL Domestic/Private ❑Graver Pack ❑Tracy Dia. of Well Casing ❑ Public ❑Othe [] Delta Type of Casing ❑ Irrigation ,� Approx. ❑Eastern Specifications Cathodic Protection Depth- ❑ I Depth of Grout Seal . 1-1.Geophysical I Type of Grout � ❑Other Surface Seal.Installed by } I� Repair Workrene F Type of Pump H.P. State Work Done Well Destruction Lf Well Diameter Sealing Material (top 501 Depth �I ifFille'r Material (Below 50') "TYPE OF SEPTIC WORK: NEW INSTALLATION� REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is t14-a V I I I j available within 200 feet.) installation will serve: Residence -""`,Commercial l Other Q 44 Number of living units:. Number of bed-oms Lot size ° Character of soil to a depth of 3 fe t; -r Water table depth -0 ' SEPTIC TANK ❑ Type /Mfg Capacity ° a - No. Compartments 1 PKG. TREATMENT PLT. ❑ Tiype/Mfg / Capacity Method of Disposa) .F Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. & LengthTof lines if T Total yength/size d FILTER BED ❑ 5fistance to nearest: Wel 1p- Bp Q Foundation - Property Line SEEPAGE PITS [) w Depthe .0-.t Size d Number SUMPS F-1Distance4to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ `+ I hereby certify that I have prepared.thislapplication 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:r'I.certify that in the performance of the work for which this permit is issued, Il.shall not employ any person in such manner as to'becomemsubject to workman s compensation laws ofiCalifornia." Contractor's hiring or sub''-,contracting signature certifies the,following: "I certify thatlin ,the performance of the work for which this permit is issued, I shall employ persons'subject'to workman's'compensation laws of'California:" ( The applica s cI �o�r�equire �!�nspections. Complete drawing on reverse side. y l Signed X Title: Date: a7 E. R RTMENI' UPE'-ONLY Application Accepted by f # y,, V Area ` ❑ St 466-6781 Additional Comments /!! c —„,,�,��❑ Lodi 369-362.1 Pit or Grout Inspection by Oat Q”Manteca,823-7104 Final Inspection .by Date r ��..,,❑-Tracy,a 835 6385 Applicant - Return all copies to; Envi• ental Hehlth Permit/frvices 1601 E. Hazelton Ave., P.O. Box 20419 S;k1, CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO'� INFO - - k EH 13-24 REV. 10/82 j `� —10/82 500 t 14-26 !�� "