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APPLICATION FOR PERMIT . f. SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E, HAZELTON AVE_ STOCKTON, CA PERMIT N0, Telephone (209) 466-6781 DATE ISSUED 45-10— PERMIT lGLPERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ' 4- Application Application is hereby made to the San Joaquin Local Health District for a permit to construct-and/ar 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 aguin Local Health District. Job Address/ Subdivision Name Owner's Name * ' Address Z / Phone Contractor's Name License No. Z Phone �} _ 1 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ 1 t I DISTANCE TO NEAREST- .SEPTIC TANK ; SEWER LINES DISPOSAL FLD. PROP. LINE kFOUNDATION, • ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0� Industrial ❑ open iBottom Manteca Dia. of Well Excavation L,) Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ti # Public . ❑ Others. ❑ Delta Type of Casing .fo - V Irrigation Depth E] Eastern Specifications F-1CathodicProtection Depth of Grout Seal r ❑Geophysical Type of Grout i U Other 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') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION J (No septic tank or seepage pit permitted if public sewer is I available within 200 feet.) Installation will serve: Residence )!C_ Commercial _ Other I Number of living units: Number of bedrooms _ Lot size �jQ V i Character of soil to a depth of 3 feet: o�rG-se.� Water table,depth SEPTIC TANK Type/Mfg `LAOacity "No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg{ Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well O Foundation ;;�Le r - Property Line X70 DESTRUCTION ❑ fTotal length size ?� Q LEACHING LINE � No. & Length of lines Foundation i Property Line �Q FILTER BED L] Distance to nearest: Well J . SEEPAGE PITS [j Depth Size x Number # SUMPS �� Distance to nearest: Well .Foundation Property Line DISPOSAL PONDS ❑ 3 ' 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 Jo'Auin 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, 1 shall not employ any.person in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-CDntracting signature certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall employ ns subject to workm 's compensation laws of California."• The applic call for 1 requi insp'tions. Complete raw n reverse side. �� G Signed X , Title: Date: a D P `ENS E N 4x ❑ Application ,Accepted by ea � 5tk 466-6781 ❑ Additional: Comments: Lodi 369-3621• Pit or Grout .Inspection by' Date + t ❑ Manteca 823-7104 Final Inspection by Date 7—J ❑ Tracy 835-6385 Applicant - Return all copies to:'. Envir ntal Health Permit/Services 1601 . Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED i RECEIVED•BY i DATE PERMIT NO. 6 INFO ei r 47' 10/82 506/ 0 EH 13-24 REV- 10/82 14-261 ' r