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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Hea�th�DDiistrict. Job Address W.1 -0 Ma,,r7 Subdivision Name Owner's Name ' r ` Address t✓f� Phone Contractor's Name 64, 91:, License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR j OTHER ❑ (UJ DISTANCE TO NEAREST: SEPTIC TANK jf(l SEWER LINES [/[t" DISPOSAL FLD, LfO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSF—J Industrial ❑ Open Bottom t1anteca Dia, of Well Excavation r _ Domestic/Private 7_GraJel Pac_ ❑"Tracy —tia: of-Well—Casing ID Public ��F-1 Other ❑ Delta Irrigation Type of Casing � Li 9 Approx. ❑ Eastern �� Specifications Cathodic Protection Depth — ` j, 17Geophysical Depth of Grout Seal qof L)Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done' J Well Dest uction ❑ Well Diameter Sealing Material (top 50') _ 6 Or� JeDepth �/ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION FJ (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 U 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 G DESTRUCTION ❑ LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is--i:Asued, -I-shall employ persons subject to workman's compensation laws of California." The appl,icant.m 11-0°Ov.r A 1 quired inspections. Complete draw' on reverse side. J Signed!X " Title: Date: bEPAR ENT USE ONLY ,Applicat i'oh Accepaed' by �/✓ Area Stk 466-67B1 Additional Comments" Lodi 369-3621 "Pi ti or Grout Inspection by Date 'p��/ _�� Manteca 823-7104 „Final Inspectio 5-by: ' Date ❑ Tracy 835-6385 Applicant;- Return all'.c ll.,es to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 a � FEE.'` ;BASE <- AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO" . d 'moi`►was— 4S AS EH 13-24 REV. 10/82 vi" .f puf f-e_a � q6? (Jl.(1— la {ylpAf 10 �sr r 14-26 Wn,Q� �1a5 S / Q/`t • p/9I C}'aaO\ j �s�• i4r,p►�ve c� �H a- Fk-4 !