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APPLICAT10 FOR PERMIT SAN ,CAQUiN LOCAL EALTH DISTRICT 1601 E. HAZELTOd AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR-FROM DATE .,ISSUEO (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 ',� o Subdivision Name Owner's Name Address �!' ,Phone Contractor's Name License No. Phone i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ' I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i IJ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ! Public Other Delta ❑ C1 ❑ Type of Casing Lj Irrigation Approx.` ' [] Eastern Depth Specifications ❑ Cathodic Protection s Depth of Grout Seal ❑Geophysical Type of Grout C ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done C� Well Destruction ❑ Well Diameter? Sealing Material,(top 50') (S1 Depth Filler Material-(Below 50') O TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/AODITION l (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 bedroams Lot size Character of soil to a ,depth of 3 feet: .>dhr Water,table depth SEPTIC TANKX,'� Pe/Mfg~ Capacity No.ompartments r 'I c PKG. TREATMENT PLT. ❑ Type/Mfg' Capacity Method of; Disposal SEWAGE SYSTEM Distance,to nearest: Well Foundation Property Line* a DESTRUCTION ❑ LEACHING LINE No. & Length of lines ' Total length/size. P ` (\ FILTER BED ❑ Distance to"nearest; Well P Foundation ��f Property Line SEEPAGE PITS VX Depth �"or Size 0 or 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 thjs permit is issued, I shall not employ any person in such manner as to become subject to•workman� compensation laws of CalifornAa." I 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 ca for all required inspe ions. Complete drawing on rever e'side. Signed x Title: t Date: I OR PA ENT SE Application Accepted by } Area ❑ Stk 466-6781 Additional Comments: [ Lodi 369-3621 € Pit or Grout Inspection byDate /D Manteca 823-7104 + I❑ Final Inspection by f c ' - 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 DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ]� l 1 S • C7� �C�"` ��Z�o �S —f3 10/82 500 EH 13-24 REV. 10/82 '� 14-26