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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT 19 f, 1601 E. HA7ELTON AVE,; STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE 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 Regulations of the San Joaquin Local Health District. Job Address Subdivision Name Owner's Name 41, 6 Address Phone License No. Phone 7 Contractor's Name F[,Fd yids G - TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ —PUMP -INSTALLATI-ONSYSTE-M,.REPAIR- - ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL • PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom []Manteca - Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications r £ Cathodic Protection Depth [—] iDepth of Grout Seal ❑Geophysical Type of Grout ❑Other _ r 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 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONriL/ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence ✓ Commercial _ Other Q Number of living un-its:. Number of bedrooms • S Lot size 9ax I!_sZ Character of soil to a depth of 3 feet: el 4AZ Water table depth SEPTIC TANK ! • �T�ier►1% t Capacity No. Compartments PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line —1 DESTRUCTION ❑ - size len th f LEACHING LINE Na. & Length of lines f � Total 9 / �'� ,� FILTER BED ❑ Distance to nearest: Well r^ Foundation 2„0 r Property Line SEEPAGE PITS Depth -1,S Size Number r SUMPS Distance to nearest: Well .r■ Foundation Property Line DISPOSAL PONDS ❑ �l' j�`� 11f 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, 1 shall employ persons subject to workman's compensation laws of California." The applicant must call for all required insp •ons• Complete draw' g on reverse side. Signed X Title:- Date: r FOR DEPARTMENT USE ONLY Application Accepted by Area Stk 466-6781 Additional Comments: r [] Lodi � 369-3621 Pit or Grout Inspecti*o,: Date l ❑ Manteca 823-7104 Final Inspection by Date ,�/ ❑ Tracy 835-6385 Applicant - Return all copievironmental He th ermit/Services 1601 E. aze ton 0, P.O. Dox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATELPERIM11 N0. INFO b/l ti1 1=7 39 10/82 500 EH 13-24 REV. 10/82 14-26