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APPLICATION FOR PERMIT s r SAN JOAQUIN LOCAL HEALrTII„DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 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 Local Health District. Job Address Subdivision Name i Owner's Name Address _ _ Phone Contractor's Name T License No. — �— — Phone TYPE OF NEL'%?UY!P WORK: NEW WELL WELL REPLACEMENT DESTRLCTION❑ i PUMP INSTALLATION Q SYSTEM REPAIR - I;Lj { ;OTHER�:�] 1 DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES i DISPOSAL rLD. _ PROP. LINE FOUNDATION �- AGRICULTURE WELL OTHER 14ELL PITS/SUMPS INTENDED USE —TYPE-OF-WELL—PROBLEM AREACONSTRUCTIONSPECIfICATIONIS 17 InJustrial U Open Bottom (__ Manteca Dia, of Well Excavation L.1 Domestic/Private Gravel Pack ( Tracy Dia. of Well Casing L-] Puo,ic G Other Delta Type of Casing L_� Irrigation _ Approx. Eastern Cathodic Protection Depth Specifications — L;Geophysical Depth of Grout Seal L!Other y'pe oof'Grout Surface Seal installed by 1 Repair Work Done [:1 Type of Pump _ _ H.P. _ State Work Done I Well Destruction J Well Diameter �Sealing Material (top �0'} Depth Filler Material (Below 50') ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Fl (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 of bedrooms Lot size Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK LJ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 1_� Type/Mfg Capacity i_ Method of Disposal Septic Tank �..j"Distance to nearest: Well Foundation Property Line Destruction 1.� — LEACHING LINE -_ I—I No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation i Property Line SEEPAGE PITS s--�.� Depth' Size — SUMPS , L' Distance to nearest: Well — Foundation Prooerty Line DISPOSAL PONJS (�• 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. Hare owner or licensed agent's signature certifies the following: "I certify that in the perfr,rnance of the work for which this permit is issued, I-shall not employ any person in such minner 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 penr.it is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing or, reverse side. � Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Area F__) Stk 466-6781 Additional Comments: _ F-1 Lodi 369-3621 i Pit or Grout Inspection by Date _ __ [l Manteca 82.3-7104 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 ' A.VUNT "DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO., i f INFO -- s s - _ EH 13-24 RFV. 10;82 '" ' 10/82 500 14-26 .;