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APPLICATION FOR PERMIT F SAN JOAQUIN LOCAL HEALTH DISTRICT e n 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. lJ Telephone (209) 466-6781 6 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM 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 and ReuI tions of t e Joaquin Local Health District. Joh Address Subdivision Name Owner's Name i Address _C/�1t-. Phone Contractor's Name e License No. �Q S ]�� Phone 3 - —�— ^� Q4 W TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE —S� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4-- INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing ❑ Irrigation Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout ❑J Other Surface Seal Installed by O� Repair Work Done ❑ Type of Pump H.P, State Work Done ,. D Well Destruction ❑ Well Diameter Sealing Material (top 50')� I` Depth Filler Material (Below SO'- ILI E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ {No septic to k or seepage pit permitted if public sewer is " y tavailable within 20C feet.} Installation will serve: Residence 4,.--Commercial Other Number of living.uni.ts: Number of bedrooms." Lot size 660, --i' rr Character of soil to a depth of 3 feet: L ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Type/Mfg Capacity 3 Method of Disposal SEWAGE SYSTEM Distance to nearest:' Well Foundation Property Line E DESTRUCTION P LEACHING LINE No. & Length of lines .1 + �+� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation JV'� Property Line i SEEPAGE PITS Depth � _ Size a Number f SUMPS L� Distance to nearest: Wel l_, Foundation FProperty Line DISPOSAL PONDS ❑ 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 permit is issued, I shall not employ any person in such manner as to become subject tolworkman� 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 s call r 1 equired inspections. Complete drawing on reverse side, ,¢ Signed X - Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Area ❑ 5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspect X, � Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Replicant - Return all copi Envir amental Health Permit/Services 1601 L. zelton.Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 10/82 500;x. 04�-,\k EH 13-24 REV. 10/82 µ, ab, 14-26