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APPLICATION FOR PERMIT R SAN JOAQUIN LOCAL HEALTH DIS tt ` 1601 E. HAZELTON AVE., STOCKTON, CA JJL-;69, 3 1922 4 PERMIT NO. Telephone (209) 466-6781 DATE ISSUED'] - PERMIT EXPIRES 1 YEAR FROM DATE IS IN JO lI ;,� L0Cf_:L (Complete in Triplicate) HERLTH DZYMY 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 nd Regulati ns o�he San Joaquin,yo5o Health District. ;# Job Address -J 1 Subdivision N e Owner's Nameajg Address Phone Contractor's Name _/}� �� Z �. License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAO FLD. " PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _171-Industrial - -E)Open Bottom Manteca Dia. of Well Excavation RI—Domestic/Private Gravel Pack Tracy Dia. of Well Casing } Public E]Other Delta Irrigation Type of Casing li LJ 9 Depth Eastern Specifications I� Cathodic Protection Depth Depth of Grout Seal r, [�Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ik Well Destruction [� Well Diameter Sealing Material (top 501) 1 Depth Filler Material (Below 50') 9 TYPE OF SEPTIC WORK: NEW INSTALLATION [JREPAIR/ADDITION U (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 [ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE [J_ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ Depth Size Number = SUMPS jJ Distance-'to"nearest:`-'Well,--'^ 'Foundation- �'Prvperty-Li ne= DISPOSAL PONDS [� r 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 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 on reverse side. Signed X Title: 1C Date: EPA TMENT E Y � •� Application Accepted by Area c �� Stk 466-6781 Additional Comments: F-1 Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date V_5a /J� ❑ Tracy 835-6385 Applicant - Return all copie Envirkn`m al Health Permit/Services 1661 E. Ha elton A/e., P.O. Box 2009, Stk., CA 95201 I�. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATE PERMIT NO. INFO 4S. ,o " C&= EH 13-24 REV. .10/82 10/82 500 14-26 w ��