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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT E(4- q 5v I 1601 E. HAZELTON AVE., STOCKTON, CA,- PERMIT NO. Telephone (209) 466-6781 t�—zp$L�• . DATE,ISSUED 4 PERMIT 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 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 , Subdivision Name Owner's NameYK_d�d�r/ess Phone �— Contractor's Name /y 7A feAe No. Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK "Pk� S WER LINES DISPOSAL FCD. PROP. LINE41 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation IJ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing (A ❑ Public ❑Other ❑Delta Type of Casing L-11rrigation Approx. ❑Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal � ❑Geophysical Type of Grout ❑Other _ _ _ _ —Surface_.Sea]_Installed.by = Repair Work Done ❑ Type of Pump $U _H.P. 1" State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) j Installation will serve: Residence _ Commercial _ Other IE 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 Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ - _ ,Property,.Line. SEEPAGE PITS ❑ Depth 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 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, T shall employ persons subject to workman's compensation I•aws-of Cali-fornia-.—, The applicantsDust cal for all required inspections. Complete dra ' g o reverse side. Signed X Title: Date: / OR R NT USE.ONLY - . _ . Application Accepted by Area rpt- Stk 46fi-6781 Additional Comments: E] Lodi 369-3621 i • Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final inspection by G. __ Date Q ❑ Tracy, 835-6385 Applicant - Return all copies to. Environment 1 health Permit/Services 1601 E. Hazelton A e., P.R. Box 2009, St k., CA 95201 r FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE p PERMI�T{ NO. INFO Uf. [_L .(l FV bq O I < ( 10/82 540 EH 13-24 REV. 10/82 ! 14-26