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APPLICATION FOR PERMii SAN JOAQU0: LOCAL HEALTH DISTRICT 1601 F, HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,PERMIT NO. J DATE ISSUED 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 {an�d Regulations of t aa San Joi.n Local Health District. 7�i Job Address 0.21Subdivision Name Owner's Name Contractor's Name TYPE OF WELL/PUMP WORK. NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK FOUNDATION Address Phone License No. 3 - 7 Phone WELL REPLACEMENT DESTRUCTION ❑ SYSTEM REPAIR OTHER ❑ _ SEWER LINES DISPOSAL FLO, PROP. LINE AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA iJ Industrial U Open Bottom [] Manteca U Domestic/Private Gravel Pack ❑ Tracy bl' CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing ❑ Pu zc �J Other Delta Type of Casing V Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of ump H.P, .State Work Done Well Destruction Diameter Sealing Material (top 50') _ Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial _ Other Number of living units: / Number of bedrooms_ Lot size fC- Character of soil to a depth of 3 feet:: Water table depth SEPTIC TANK Type/Mfg P,51 ! Capacity1 9 D D._ No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well �„ o Foundation',( Property Line___ DESTRUCTION ❑ LEACHING LINE No. & Length of lines Total length/size p FILTER BED Distance to nearest: Well rsFoundation Property Line SEEPAGE PITS A Depth tX Size 33 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 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 iyust call for all required inspections. Complete drawing on reverse side, Signed X Title: Date: P TMENT S ONLY I Application Accepted by f" Area } - ❑ Stk 466-fi7 1 Additional Comments: Lodi 369-3 21 Pit or Grout Inspection b Date ) Manteca 823-7104 Final Inspection by %F Date Tracy 835-6385 Applicant - Return all copies to: vi 6nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [FEECBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO S3 Q - 9a EH 13-24 REV. 10/82_ 10/82 500 14-26 ©�.t� OCS,/zoy--, �,�, um-rr-1 -- /1/4