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awl— APPLICATION wl-APPLICATION FOR PERMIT �7�J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, s Telephone {209} 466-6781 ��`•1!- 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 a Reg ati of the San Joaquin Local Health District. Job Address Illi �`}f 40 r Subdivision Name Owner's Name 1 s/ ddress A_Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL LL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATIO VSYSTEM REPAIR Cl OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -10 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE —TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Ind trial J Open Bottom Manteca Dia. of Well Excavation mestic/Private avel Pack Tracy Dia. of Well Casing +/. ❑ Public Other Delta Type of Casing [1Irrigation Approx. Eastern []Cathodic Protection Depth Specifications Depth of Grout Seal 67 Geophysical Type of Grout U Other Surface Seal Insta 1 ed by e- L /,''} Repair Work Done ❑ Type of Pump �_ H.P. State Work Done Well Destruction (J Well Diameter Sealing Material (top 50') _ r Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (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 �I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE L 1 No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS IJ 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' ature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall no emplo a p son in such manner as to become subject to workmanb compensation laws of California." Contractor's hirin or ub tra t i n ture ertifies the fallowing: "I certify that in the performance of the work for which this permit.i is ed, a e p so su 'ect to workman's compen tion laws of California." The applic 1 r al i ed ions. Completed wir vers sj{1e.` f�r '1�1 Date: Signed X Title: FDR DEPART NTSE NLY Application Accepted b}�✓ 2 Area �&Stk 466-6781 Additional Comments: EJ Lodi 369-3621 Pit or Grout Inspection by Date Z' Manteca 823-7104 Final Inspection by Date `� Tracy 835-6365 Applicant - Return all copies to: Environmental ealth Permit/Services 160 E. azel on AyO, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N . INFO — 3-� u-t7 EH 13-24 REV. 10/82 10/82 500 14-26