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' APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 he San Jo quin Local Health District, k Job Address I Subdivision Name Owner's Name Address ` Phone + Contractor's Name ' pf f' ense No. 0 Phone7�7 TYPE DF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION/S fl'Al 'PUMP INSTALLATION SYSTEM REPAIR OTHER I 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 '' : CON$TRUCTION":SPECIFICATION$ -71 lndus'tridl- .. ,.. _u Open"bottom ^- El Manteca .,'- "" 'Dia."of Well Excavation"--w - ----�-4- -, .. Elro-mestic/Private ❑Gravel Pack Tracy Dia. of Well Casing ❑ Public 71 Other Q Delta Irrigation I Type of Casing V 9 Depth Eastern Specifications Cathodic Protection �p �. ❑Geophysical Depth of Grout Seal ❑Other Type of Grout i Surface Seal Installed by Repair Work Done Type of Pump l , N.P. State Work Done Well Destruction ❑ Well Diameter ` ; Sealing Material (top 501) 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 available within 200 feet.) Installation will serve: Residence _ ' Commercial _ Other Number of living units: Number o bedrooms Lot size Character of soil to.a depth of 3 feet: p �� _„�Water�table,depth SEPTIC TANK �j Type/Mfg Capacity iNo. Compartments rV PKG. TREATMENT . Type Mfg Capacity I Method of Disposal- I SEWAGE SYSTEMDistance to neares=t WelI Foundation Property Line L DESTRUCTION ❑ t LEACHING LINE ❑ No. & Length of lines Total length/si•ze�----�-•-.- •�-- - w-.,;,FILTER BED_ Distancetonearest Well Foundation Pro`pertytLi'n' SEEPAGE PITS f—j Depth — Size Number -� y f -- __ _ „ -- , SUMPS �� Distance to nearest; ° Well �.-,Foundation propert_ yy Line 1 DISPOSAL PONDS I hereby certify that I have t pp il � - �. cord e Y Y prepared this a lication and that the work will be"done in accordance with San Joaquin county ordinances, state laws, and rules and regula•ti-dns of the San Joaquin Local cal_Health District. Home owner or licensed agent's signature cerfi-fies the following:°I certify tFat in the performance o1"the-gork"for which this permit is issued, T 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 m t call for 1 required iiipections. Complete drawing on reverse side. G Signed X Title: Date: 0Z FOR Ott ARTMENT USE ONLY App kation Accepted by [ Area ❑ Stk 466-6781 Additional Comments: # Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-710,4 Final Inspection by Date _'• Tracy—. B35-6385 ' Applicant - Return all copie to: ironmental Health Permit/Services 1 E. H elt n Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT.REMITTED RECEIVED BY DATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 14-26