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APPLICATION FO.R PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ¢ 'J`�- 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, O 3` Zq Telephone (209) 466-6781 . DATE I55UEDi1 2.5 43 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 t e SaA.Joaquin Local Health District, j Job Address Ku Subdivision Name 4 � �, Owner's Name Address - Phone Contractor's Name6 License No. �, T (, Phone TYPE OF WELL/PUMP WORK: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL k OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal .4� ❑Geophysical Type of Grout Other Surface Seal Installed by (h Repair Work Done ❑ Type of Pump H.P. State Work Done _ l Well Destruction ❑ Well Diameter Sealing Material (top 50') M Depth Filler Material_(Below 50') ' J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION &d--Mo 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 _E!,_. Lot size 1` Character of soil to a depth of 3 feet: 10— Water table depth d SEPTIC TANK E-t—' Type/Mfg AIL Capacity IM, No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal O SEWAGE SYSTEM , Distance to nearest:w Well 4Q Faundatian Property Line r DESTRUCTION ❑ LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation e Property Line SEEPAGE PITS Eq<2 Depth t Size [ ��e Number �r SUMPS a Distance to nearest: Well F ,, 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 t compensation laws of California." Contractor's hiring or sub-contracting signature certifi65'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 applit mu1 f�allrequired inspections. Complete drawing onreverseside: Signed Title: Date: &OEPARTMENT 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 3 ❑ Tracy 835-6385 Applicant - Return all copie to: . Environmental �ealthPermit/services 1601 E.,Hazelton Ave., P.D. Box 2009, Stk., CA 95201 r1N BASE AMOUNT DUE AMOUNT REMITTED RECEIVED" 8Y DATE PERMIT NO. O '93— 1�7 9 Z JJ� O / 4 ! l 10/82 500 EH 13-24 REV. 10/82 14-26