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APPLICATION FOR PERMIT _ SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. (�! Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AtOMNk 0 DATE ISSUED 7 (Complete in Triplicate) . %,s; py 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 Regulations of the San Joaquin Local Health District. Job Address_ j "' r( Subdivision Name —LJ5�7—&A Owner's Name hA., AL Address C; Phone Y,-7 -5A' Contractor's Name<c-'_tSt Cr-A Y►y Sem cense No.S9i y Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U l� DISTANCE TO NEAREST: SEPTIC TANK ��°s � SEWER LINES DISPOSAL FLD. 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 Li [�Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public [ Other [] Delta -� Type of Casing Irrigation .�Q Rpprox. � Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal b Other Type of Grout ,, Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �c TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer isI( 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 m SEPTIC TANK• �I Type/Mfg Capacity No. Compartments PKC, TREATMENT,PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & 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 I DISPOSAL PONDS I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ; `t 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 j permit is issued, I shall not employ any person in such manner as to become subject to w&kMP n� 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 I ;i this permit is issued, I shall employ persons subject to workman's compensation laws of California;" The applicant must call for all requir d inspections. Complete drawing on reverse side. 1i Signed X Title: Date: 2-7 DEPARTMENT USE ONLY Application Accepted -byArea (51 r Stk 466-6781 Additional Comments: 1� S�;a , itv+ c..w ',• -.��c 4r- Lodi 369-3621 1, Pit or Grout Inspection by Date - 3 Manteca 823-7104 { Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Healt Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 lir FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 1 INFO II ,EH 13-24 REV. 10/82 fQe 10182 500 I 14-26 i