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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 GATE 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 Rules and Re lati;p of the n Joa in Local Health District. Job Address Owner's Name Address Phone Contractor's Name License No. 2& Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT [ DESTRUCTION ❑ F. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �1 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 oL� 17 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack [] Tracy Dia, of Well Casing T __ i' ❑ Public ❑j Other ❑Delta Type of Casing T ❑ Irrigation Approx. ❑Eastern Specifications Cathodic Protection Depth F-1Depth of Grout Seal f Gea h sicaI f." ❑ P Y Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') C Fi TYPE OF SEPTIC WORK: NEW INSTALLATION [J7 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 b drooms _ Lot size l ' Character of soil to a depth of 3 feet: _ Water table depth f �✓ _ Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION .^ Total length/size LEACHING LINE VC No. A Length of lines / � FILTER BED ❑ Distance to nearest: Well / Foundation 0 / Property Line SEEPAGE PITS Depth �� _ size 1J _ Number _"/ SUMPS U Distance to nearest: Well D Foundation —�G Property Line DISPOSAL PONDS that I have prepared this application and that the work will be done in accordance with San Joaquin county ! hereby certify p p P 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 issued, I shall employ persons subject to workman's compensation laws of California." The applica t m t call for all requ' ed inspections. Complete dra ing on reverse side. Signed X Title: Date: �� FOR DEPARTMENT USE ONLY App ication Accepted by Area ❑ 5tk 461-6781 Lodi 369-3121 Additional Comments: Fi Pit or Grout Inspection by 0ate Manteca 823-1104 Final Inspection by Date )] Tracy $35-6385 Applicant - Return all copies . Environmental Health Permit/Services lb" E. azelton Ave., P.O. Box 2009, Stk., CA 95201 C FFEE � BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0g2 i 10/82 500 EH 13-24 REV. 10/82 14-26