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L7 FI APPLICATION FOR PERMIT SAN JOAQUiN uy LOCAL HEREIN D15TRICT , JUN 1 1�+Q8 1601 E. HAZELTON AVE., STOCKTON, CA PERh1IT NO. Telephone (209) 466-6781 SANJOA i UIN DATE ISSUED SAN HEALTHHEALTH !q LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ®iSTRICT (Complete in Triplicate) kk Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein i 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 Owner's NameAddress n Phone 1-? \\!!, Phone t� Contractor's Name ��,., ._. License No, f ,l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w li, PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE Jr FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ro-m ustrial—' "❑ Open'Bottom �] hlanfecaDia: onof Well Excavatiestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing r ❑ Public C Other [] Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ••t ❑Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done 1 a /ter II Material to 50'Sealing a ( ) Well Destruction Well Diameter g P Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION C.a REPAIR/ADDITION L� (No septic tank or seepage pit permitted if public sewer is !II 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 ❑ Type/Mfg Capacity No. Compartments TREATMENT PLT, Type/Mfg Capacity Method of Disposal PKG, TRE U SEWAGE SYSTEM Distance to nearest. Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size I FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number _ r SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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 owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this k permit is issued, I 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 must call for all required inspections. Complete drawing or reverse side. Signed X as Title: 4, Date: ' FOR D PARTMENT USE ONLY Application Accepted by Area _ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout InspectionAy Date ❑ Manteca 823-7104 Tracy 835-5385 �— � L Ej Final Inspection by c�" Date —�7„�4V—�- 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 N0. INFO �010 J?�LC J" r C� - +O U l }o . 10/82 500 EH 13-24 REV. 10/82 14-26 a Y