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APPLICATION FOR.PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED G 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 Name AddressSA 1 Phone Contractor's Name License No, Phone �� +d� I TYPE OF WELL/PUMP WORK: NEW!WELL ❑ WELL REPLACEMENT DESTRUCTION S ,PUMP INSTALLATION,❑ e .SYSTEM REPAIR D. OTHER U � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE )i FOUNDATION ) AGRICULTURE WELLOTHER WELL PITS/SUMPS ' _ INTENDED USE TYPE DF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- r �I Industrial U Open�Bottom []Manteca Dia, of Well Excavation L,I Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public El Other Delta i Type of Casing �j Irrigation -Approx.— F-1 pprox. Q Eastern Cathodic ProtectionDepth Specifications Depth of Grout Seal 1-1 Geophysical Type of Grout U Other - Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done C Well Destruction U Well Diameter' Sealing Material (top 501) Depth '1 Filler Material (Below 50') Y I TYPE OF SEPT�aC WORK: NEWNEW INSTALLATION I REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if ,public sewer is I `^ / 400 available available within 200 feet.) Jl Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms ..Lot size I Character of soil to a depth of 3feet: Water table depth I SEPTIC TANK Type/Mfg Capacity " No. Compartments �l PKG. TREATMENT PLT. Type/Mfg Capacity Method'.of Disposal i I SEWAGE SYSTEM Distance to nearest: Well Foundation _—Property,Line DEST CTION LEACHING LINE U No. & Length of lines _ A i 4 Total length/size FILTER BED Distance to nearest: Well t Foundation Property Line SEEPAGE PITS CI Depth } +Size Number SUMPS Distance to,near'est: Well Foundation Property Line DISPOSAL PONDS O 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 workmant compensation laws of California." 1' Contractor's hi ng or sub-con trac£ing signatur certifies-the'fol]owing: "I certify that in the performance of the work for which this permit is i sued, I shall employ p ons b.ect to workman's compensation laws of California." Theapplica m for requir i pe do Comp ete g on reverse side. k Sign'ed X , itle: _S Date: 9—aL, Y ¢ EP ENT ONLY ,yr Application Accepted by F ONLYArea � `�Stk 466-6781 Additional Comments: i d• Lodi 369-3621 Pit or Grout Inspection bv, . . Date LL7 Manteca 823-7104 Final Inspection by L Tracy 835-6385 Applicant - Return les to v ar - t r } v 1 tonp�e� gg0.ti.Box 20 k., CA 95201 :' 1. c ( s wXrf�TLC s FEE BASE AMOUNT DUE AMOUNT REMITTED RLCEIVED,BY, DATE F PE NO. INFO P - ° '1:: >f+ti, .'.. : yt' EH 13-24 REV. 10/82 10/82.500 14-26