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R&0_� APPLICATION FOR PERMIT SAN JOAQUi?i LOCAL. HEi%LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 C!' DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete-in Triplicate) Applicatior 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 Joaquin Local Health District. IV 1 Job Address 9 Ila Subdivision Name Owner's Name dress OEPhone Contractor's Name icense,No. Phone ,3 r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `li ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -� omestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑j Other ❑ Delta Type of Casing ❑ilrrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth_ of Grout Seal ❑ Geophysical Type of Grout Other --. �'� _ t, Surface Seal Installed by Repair Work Done'G Type of Pump * H.P. State Work Done Well Destruction LJWell Diameter Sealing Material (top 50`) .' Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION LI 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: Number of bedrooms Lot size sS ; Character of soil to a depth of 3 feet: Water table depth #'1 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 i. f 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 LI 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manrer 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 a this permit is issued, I shall employ persons subject to workman's compensation laws of California." i The applica mustc for all required 'ns ections. Complete dr 'ng on r si p Signed X Title: Date: d OR DEP RTMENT U7 ONLY 'I Application Accepted b Area ❑ Stk 466-67 Additional Comments: Lodi 369-3621 Pit or Grout Inspection bO. Environmental Date ❑ Manteca 623-7104 Final Inspection by Date -�2� ❑ Tracy 835-6385 Applicant - Return all copies t Health Permit/Services 1601 E. Hazelton A10, P.O. Box 2009, Stk., CA 95201 ; FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY tDATEt'' PSE/RMIT NO. INFO _�!y r �1� {pmt g'Y 8 l'��P-I. , EH 13-24 REV.• 10/82 LJ� i '] '" 10/82 500 14-26