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APPLICATION.FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTR C ` 1601 E. HAZELTON AVE., STOCKTON CA J (� P'�.'PERMIT NO. --1 Telephone (209) 466 -6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pl 'v-T`k� � s1�F <DATE ISSUEDvi R (complete in Triplicate) rr,6 fat% Application is hereby made to the San Joaquin Local Health District for 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 H lth District: c Job Address Subdivision Name .7. Owner's Name Address p�; ' Phone Contractor's Name License No. ' a' -,Phone ` TYPE OF WELL/PUMP WORK: NEW WELLEL ❑ W L REPLACEMENT EJ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK a 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 M�Wmestic/Private E]Gravel Pack F� Tracy Dia. of Well Casing ` Public Ej Other' ❑ Delta # Type of Casing LJ Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Q ❑Geophysical Other Type of Grout a' Surface Seal Installed by u Repair Work Done ❑ Type of Pump H.P. State Work Done 1pk Well Destruction ❑ Well Diameter Sealing Material (top 501) V1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer. is i available within 200 feet.) Installation will serve: Residence _ Commercial _ Other p 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 QUO DESTRUCTION ❑ 1 LEACHING LINE ❑ No: & Length of lines Total length/size > FILTER BED ❑ Distancelto nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number BURPS `" -jam Distance{to nearest: Well `Foundation�"�^^ - " Pr`operty-Cine"^' x DISPOSAL PONDS 4 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 insuch 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 employ persons subject to workman's compensation laws of California." The applicant est call for all required inspections. Complete drawing on r ve se side, n Signed _ L Title: , Date: I DEPARTMENT E ONLY '��—�r Application Accepted bea !J } Stk 466-6781 i/ /lr Additional Comments: i = Lodi 369-3621 Pit or Grout inspection b Date C� Manteca 823-7104 Final Inspection by — DateL7`� Tracy 835-6385 Applicant - Return all copies to.- .,Environmental Health Permit/Services 160101�Haa7eltonQ7 Ave., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO 177 EH 13-24 REX. 10/82 10/82 500 14-26