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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 p3PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 n Re ulations of the San Joaquin Local H alth District. " /� Job Address 7 Subdivision Name gr�iy21V hc4tys jot/,wclyk? Owner's Name Address Phone Contractor's Name item se No. �� l% Phone14 4 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE UJ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ) INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation F-1 Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing Public E1 Other Del to Li Tp ee of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) ._ Depth Filler Material (Below 50') -� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or see uge 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED f-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS EJ Depth I Size Number SUMPS i w ':�K !S Distance to nearest: Well 40D Foundation Property Line levee J 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% 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 em Icy persons subject to workman's compensation laws of California." The applicant 11 f r all q 'red inspectio plete drawing on reverse aside. 01 Signed % le: f)Y17YC/_J Date: /0-16 Application Accepted by �-- DD PA USE ONLY Area 4 Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b Date LE] Manteca 823-7104 ' Final Inspection by F Date 'p7 L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PER73_MIT N0. INFO r , 11 EH 13-24 REV. 10/82 10/82 500 14-26