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1 APPLICATION FOR PERIM1T SAN 10AQUir, LOCA_ HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 465-6781 DATE ISSUED 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 Rulesa d egul ions of the San Jo ouin Local He District. Job Addressaelsl . division Name Owner's Nam Address b/Phon e Z R Contractor's Nam :J �/i!j Gr' License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ W REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Indu trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Fetomestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing i ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout D Other '! Surface Seal Installed by Repair Work Done ❑ Type of Pum H.P. �— State Work Done W Well Destruction ❑ Well Diameter Sealing Material (top 501) _ 41` Depth Filler Material (Below 50') W` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is amu+\] available within 200 feet.) Installation will serve: Residence _ Commercial Other 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 j�J 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 Q DISPOSAL PONDS ❑{ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county V 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 workmanl; compensation laws of California." Contractor's r'ng or sub-cont#empl 4gnaturrtifies the following: "I certify that in the performance of the work for which this permit sued, I shall ct toworkman's comp satlon laws of California." The appli t t call or alls. Complete dr g,on reverse side.Signed X Title: Date:MENT USE 0 y Application Accepted by Area �� --- ❑ Stk 466-fi181 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ��}� _ / lLfi ❑ Manteca 823-7104 Final Inspection by Date �i —�y q f ❑ Tracy 836-6385 Applicant - Return all copies to: E1160onmental Health Permit/Services 16-0711 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 rFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. NFO k-15 o m Im J - f EH 13-24 REV. 10/82 10/82 500 14-26