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APPLICATION FOR PERMIT SCA, C/;;j'—IRT�D SF.h JOAQLi.. LOCA; HeALTH JiSTRICT /�° fy 1601 E. HAZELTON AVE., STOCKTON, CAPERh1I7 N0, 53- }� Telephone (209) 466-6781 g PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED —83 (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 iJs 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 San Joaquin L cal Health District, Job Address ,1104 Subdivision Name Owner's Name ' Address .2162a Phone Contractor's Name License No. Phone (` TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U 3 , PUMP INSTALLATION SYSTEM REPAIR OTHER L DISTANCE TO NEAREST: SEPTIC TANK s°Sfi SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial LJOpen Bottom [ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack [J Tracy Dia. of Well Casing tr_ �❑ Public F-1 Other E] Delta Type of Casing pltl_ L Irrigation Approx. Eastern Depth Specifications Cathodic Protection P Depth of Grout Seale of- Geophysical U Other Type of Grout Surface Seal Installed by Repair Work Done [J Type of Pump H,P. State Work Done Well Destruction LJ Well Diameter Sealing Material (top 50') _ fy Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/,ADDITION J (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 t ► 1 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 ❑ �1 LEACHING LINE L) No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS LI Depth Size Number {]� SUMPS Ll 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 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's 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant must cal for a r quired inspections. Complete drawing on reverse side. Signed X � Title: _ �/� CCl� Date: � 3 FA DEPARTMENT USE ONLY Application Accepted by Area a 3 0-1Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date D Manteca 823-7104 Final Inspection by Date - — L Tracy 835-6385 Applicant - Return all copi s Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 73' 5�K EH 13-24 REV. 10/82 10/82 500 14-26