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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, a (O! Telephone (209) 466-6781 , DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A (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 'Loc&I Mea th District. Job Address o� $.�tt ubdivisian Name Owner's Name Address Phone Contractor's Name f License No. Phone - r 1 to TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ J DISTANCE TO NEAREST: SEPTIC TANK n-) r{ SEWER LINES 5C) r _ DISPOSAL FLD. PROP. LIRE FOUNDATION a'0 �# AGRICULTURE WELL 5j)'f� OTHER WELL PITS/SUMPS_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private 2LGravel Pack ❑Tracy Dia. of Well Casing / 6 ❑ Public ❑1 Other [] Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications JZ ❑Cathodic Protection Depth Depth of Grout Seal 4Z i p ❑Geophysical _,. , Type of Grout GLsvC-Ak Other ; Surface Seal Installed by _C)6fu / p Repair Work Done ❑ , Type of Pump H.P. State Work Done Well Destruction ❑ JWell Diameter , Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will server Residence _ Commercial _ Other Number of living units: -Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg _ Capacity Method of Disposal Septic Tank Distance to nearest" Well Foundation Property Line Destruction LEACHING LINE ❑ No. & Length of lines Total length/size'a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS EJ Depth Size Number SUMPS f-1--Distance to nearest:"'Well ""Foundation Property Line DISPOSAL PONDS ❑ I 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 owne r-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 workman� compensation laws of California." Contractor's hiring or sub-c tracting ignature certifies the following: I certify that in the performance of the work for which this permit is issued, h em y ersons subject to workman's compensation laws of California." The appli st cal f 11 a inspections. Complete drawing on reverse side. \ Title: � }E/�x1 Date: 4 -AEC Signed _ - - E ENT USE ONLY FO ` Application Accepted by Area ❑ Stk 466-6781 Additional Comments: LD 369-3621 Pit or Grout Inspection by Date �' Manteca 823-7104 ( Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DOE AMOUNT REMITTED RECEIVED BY DATE p PERMMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 C� J' 14-26 #