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APPLICATION EOR PERMIT SAN JCAQtIN LOCAL HEALTH DISTRICT 1601 E. HALELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. (J DATE ISSUED U 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 Ree/ula ons of the San Joaquin Local Health District. ,lob Address ( �yJ C.t/� 5v6d� vi smarm aa�ae Owner's Name 4f Address :)(;0 ie Contractor's Name License No. Phone`Z�� - E TYPE OF WELL/PUMP WORK: NEL! WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation I Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. [-]Eastern Specifications Cathodic Protection Depth El Cathodic of Grout Seal ❑ Geophysical Type of Grout ❑ Other / Surface Seal Installed by Repair Work Done X Type of Pump ( [ L H.P. State Work Done (12 Well Destruction ❑ Well Diameter Sealing Material (top 50') iJ Depth Filler Material (Below 50') 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: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. [] Type/Mfg SEWAGE SYSTEMDistance to nearest: Well DESTRUCTION ❑ Lot size Capacity Capacity Foundation Water table depth No. Compartments _ Method of Disposal Property Line LEACHING LINE ❑ Na. & 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 DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance§, 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 workrnant 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 perm.t is issued, I shall employ persons subject to workman's compensation laws of California." The applican = u cxtF�for all required inspections. Complete d ving n reverse side. r Signed X . ll�� Title: �►�� Date: fig DEPARTMENT USE ONLY Application Accepted bye �__ Area Stk 466-6781 Additional Comments:-. - Lodi 369-3621 Pit i'or ,Grout Inspection by ' Date Manteca 823-7104 Final Inspection byDate _U"4:m , o ✓ar L7 Tracy 835-6385 Applicant - Return all copie nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED INFO EH 13-24 REV. IO/8214-26 . RECEIVED BY DATE PERMIT NO. 10/82 500