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APPLICATION FOR PERM! SAN JOAQLIN LOCAL HEALTi DISTRICT 1601 E. HA7ELTON AVE„ STOCKTON, CA PERMIT NO, _JL4 A�� Telephone (209) 466-6781 DATE ISSUED 3 PERMIT EXPIRES I 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 f the San Joaquin Local Health District. Job Address c}37 Subdivision'1N @� �?-rz- Owner's Name ` r / X4 Address_ i/5'f( Phone 36 ra Contractor's Name U-rLk dv License No. L Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ] SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Industrial U Open Bottom r7 Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing , Public ❑ Other Delta irrigation Type of Casing I—i 9 Approx. E] Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'} Depth Filler Material (Below 50') (O -Cb- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION �� / ❑ {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} Installation will serve: Residence _ Commercial _ Other Number of living units: f Numbered rooms j i Lot sizetf� Character of soil to a depth of 3 feet: Water table-depth /-o 1.r SEPTIC TANK LF' Type/Mfg Capacity No. Compartments �- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Foundation p Property Line A ❑ LEACHING LINE U No. & Length of lines Total length/size 0 FILTER BED Distance to nearest: Well Foundation j b w Property Line .� SEEPAGE PITS Depth 'Z)' � Size �1'�ri .Z ` Number SUMPS L l Distance to nearest: Well 00 L41Foundation Property Line Tom_ 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 applica must ca for all required inspections. Complete drawing on reverse side. Signed x Title: Date: FO PARTMENT USE ONLY Application Accepted by -�� Area ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date. Manteca 823-7104 Final Inspection by � Date �� Tracy 635-6385 Applicant - Return all copies [to: Environmental 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. INFOJ:,,, LAS: Li EH 13-24 REV. 10/82 10/82 500 14-26