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APPLICATION FOR PERMIT j SAN JOAQUIN LOCAL .HEALTH DISTRICT r 1601 E. HAZELTOTelephone AVE., 66-678STOCKTON,'CA PERMIT N0, Telephone {209} 466-6781 -�a,-�--- a-- ' . PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED DATE ISSUED' � (Complete in Triplicate) �f �` �� Application is)hereby made t the�San Joaquin Local Health District for a permit to construct and/or install the work herein (7 described. This application is,.made in compliance with San Joaquin County Ordinance No. 549 far sewage or Na. lSb2 for well/pump .r and the Rules,• d Regulat ins of�theS�an Jo u. Local H althnJ District. Job Address ' r Su6division Name Owner's NA Address Contractor's Name c e,No. Ph he -e Sl TYPE OF WELL/PUMP WORK: NEW WELL WELL PLACEMENT ❑ , _ DESTRUCTION ❑ ' —PUMP INSTALLATION' - t OISTANCE;40 NEAREST: SEPTIC TANK �� SYSTEM REPAIR - ❑ "OTHER - ---. _._ . SEWER-•U1NE5 �--. #rs.`� '" e 1 D.I-SPOSAL.FLD:--- ROP., LINE F' FOUNDATION AGRICULTURE WEL O INTENDED USE THER WE L 1 ti PITS/SUMP - � -R- f,...�-�-� ��IYr^E F�WELL�,�P&OELEM $�RUGT¢fltt�5f?EGI�IGATI$NS-.��_�,:�•. _-..._ q� ❑ Industrial pen Sotto- r Manteca Dia, of Well Excavation c L.1 Domestic/Private ❑Gravel. PackTrac A.-. ❑errigation Other is ❑ a Dia. of Well Casing . ' * [j , A ❑ Delta Type of Casing _ f pprozr, ❑Eastern ❑Cathodic Protection Depth Specifications a ❑Geophysical Depth of Grout Seal 011 ❑Other (Type-of-Grout.-�� Re Done *� Surface Seal Installedi`by, pair �.r .Work ❑ Type of Pump A -P State Work Done .� Well Destruction❑ Well Diameter' . if Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK;,NEW N1 STALLATION ❑ REPAIR/ADDITION (No septic septic tank yr seepage pit permitted if public sewer is Installation will serve: Residence _ 'Commercial _ Other, available within 200 feet-) f.' Number of living*units; Number of bedrooms Lot size Character o.f soil to a depth of 3 feet: SEPTIC TANK ❑' TWater table depth Type/Mfg Capacity PKG. TREATMENT PLT. E] No. Compartments Type/Mfg ' SEWAGE SYSTEM Capacity Method of Disposal DESTRUCTION ❑ D�stance'to nearest: Well FoundationProperty Line ' LEACHING LINE Y ❑ No. & Length of lines Total length/s-ize ` FILTER BED ❑ Distance to nearest: Well M � Foundation � Property Line SEEPAGE PITS�.__ ._ �. h_ Size, _ -.� FSUMPS lJ Distance to nearest: Well F - T--- oundation ty Line,. ,. DISPOSAL PONDS ❑ Proper �%�; --------------- 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 theiSan Joaquin Local Health District: Home owner or licensed agent's signature certifies the foil'owirig: "I certi-fy-that--in the \ N + permit is issued, I shall not employ an , performance of the .work for which this ' :Contractor's hiring d sub-contracting signature�certifiesnthe f61lowto ing: "I ecome scertifytthatrin the cperformance,ofw'thefwCa 1 orkifornwhich s. this permit is issued, I shall p persons subject to workman's compensation laws of California," The applicant ust call or all r uired ins ctions. Complete d ing on reverse side. �. . Signed X 7 TStle: _ F EPARTM T USE 0 Date: Y o App ica ion Accepted by 1 �+l t> Area A ditional Comments: ❑ Stk 466-6781 Pit or Grout Inspection by Lodi 369-3621 Final Inspection by �• Date ❑ Manteca 823-7104 ' Date ❑ Tracy 835-6355 Applicant - Return all copies to: Environmen al Health Permit/Services 1601 E. Hazelton Ave., P.O. 'Box 2009,.Stkf, CA 95201, FE INFO E BASE !AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT NO� � Eli 13-24 REV. 10/82e 10/82 500 ,