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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL.HEALTH DISTRICT 1601 E. HAZELTON 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 works 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 o 0 Subdivision Name Owner's Name r ` Address hone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [] OTHER ❑ 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 ❑ Industrial ❑Open Bottom ❑ Manteca pia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy ,Dia.. of Well aCasing t I Public ]to L� � ❑Other DeType of 'Casing U Irrigation Approx. ❑ Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical + ! Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Q� Well Destruction ❑ Well Diameter Sealing Material (top 501) r 'k Depth Filler Material (Below 501) f TYPE OF SEPTIC WORK: NEW INSTALLATION U 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 bedrooms Lot size i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method. of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LJ No. & Length of lines Total length/size1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to rest• Foundation Property Line DISPOSAL PONDS CI �Pi(,. N� -�{ p j� 2)ri''�' /�ti•••:7;� { 271 j•! 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. Nome 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 employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X �°,� —2dJ �y[J Title: Date: e �?f Z i FOR DEPARTMEN E ONLY 3 Application Accepted by Area Q 5tk 466-6781 Additional Comments: ^T� ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by _ ¢y -7— Date z ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services I Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMO NT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 k 14-26