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R 1.1� 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 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 � V�//±�ZN� Address u' Phone _ Contractor's Name o" CA9-4-45License No. �r� Phone TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT [ DESTRUCTION PUMP INSTALLATION F-� 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 17 Industrial U Open Bottom ❑Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack F-1 Tracy Dia. of Well Casing Public EJ Other El Delta �� Type of Casing LjIrrigation Approx. �,r Specifications (�Cathodic Protection Depth *` Depth of Grout Seal Geophysical Type of Grout 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 U REPAIR/ADDITION [J (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 Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK [❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. F-� Type/Mfg Capacity M"etfi-d of-Ti sposal SEWAGE SYSTEM C] Distance 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 DISPOSAL PONDS ❑ - 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 an person in such manner as to become subject to workman9 compensation laws of California. Contractor's hiring or suT=contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ ersons subject to workman's compensation laws of California." The applic ust 'a fo 11 requ' d inspections. Complete drawing on reverse side. 5_!y, Signed X E, Title: �N i Date: FOR DEPARTMENT USE ONLY Area Stk 466-6781 Application Accepted by Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date L Tracy 835-6385 Applicant - Return all cap.ies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500 EH 13-24 REV. 10/82 — 14-26 -