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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ; l ; 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781, P DATE ISSUED ?PERMIT FXPIRES 1 YEAR FROM DATE ISSUED i (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 i and the Rules and Regulati s o San Joa uin Local Health Distr0 Job Address F' e CA Owner's Name eY Phone U] Contractor's Name License No. Phone J TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } PUMP INSTALl!LATION ''`SYSTEM REPAIR`,% ❑� F '' OTHFRr ❑ 'k ,; 1 DISTANCE TO NEAREST: SEPTIC TANK j 4SEWER'LINES DISPOSAL FLO. PROP. LINE i FOUNDATION { AGRICULTURE WELL OTHER WELL PITS/SUMPS A INTENDED USE TYPE-OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS ¢ Industrial LjOpen Bottom [ Manteca Dia. of Well Excavation h ❑ Domestic/Private ❑ Gravel Pack, CjTracy s Dia:--of•Well- Casing ❑ Public �j 0ther ❑ Delta *. Type of Casing F Irrigation Approx. Eastern Specifications Cathodic Protection Depth 1 ❑ Depth of Grout Seal Geophysicalg'Type ofof Grout w ❑Other . Surface Sea-V Installed by w . - Repair Work Done [f Type of Pump - '� N:RState Work'Done_ Well Destruction ❑ Well Diameter sealing Material (top"50" 'Oepth Filler Mherial (Below 50') A, r 3 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,46DITION (No'"septic tank or seepage pit permitted if public sewer is ' ,_ 11 ti available within 200 feet.) Installation will serve: Residence - Commercial Other+ l Number of living units: Number of bedrooms _ _ 1_ot size" Character of soil to a depth of 3 feet: Water table depth ,� s SEPTIC TANK ❑ Type/Mfg t S r Capacity No. Compartments 3 PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal T SEWAGE SYSTEM istanca to Barest: Well �Foundption C Property.Lin DESTRUCTION }t- s LEACHING LINE No. & Le g th of lines Total length/size Property Line FILTER BED ❑ Distance to nearest: Well _ Foundation �i ?1 _.._�W_— SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance�to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ { IZ I hereby certify that I have prepared this application and that the work will be done raccordance 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California." ollowing: "I certify that in the performance of the work for whic Contractor's hiring or sub-contracting signature certifies the fh this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant,m!!A cAli 1 required inLtions. Complete drawing on reverse side. �] _ Signed X Title: Date: / NT USE ONLY l�Q 5tk 466-678 AppTication Accepted by Area _ ��' Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b ` Date ❑ Manteca 823-7104 Final Inspection by Date — L7 Tracy 835-6385 i Applicant - Return all copies to:,' Environmental Health Permit/Services 1601 E. Hazelton Ave,;, P.O. Box 2009, stk., CA 95201 [EEZ BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, 1D/82 500 EH 13-24 REV. 10/82 14-26 f