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I APPLICATION FOR PER,",i7 SAN JOAQUI`+ LOCAL Hr.--:LTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 " J 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 Regulations of the San Joaquin Local Health District. Job Address /79 7 f Q .s,t _ Subdivision Name Owner's Nameflla� Address 77g7Z,7U_Z�_e Phone Contractor's Name ' icense No. I/ 2 Z Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM 'REPAIR. OTHER 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^-) J Industrial p U Open Bottom Manteca Dia. of Well Excavation LJ Domestic/,Private, � Gravel Pack Tracy Dia. of Well Casing . Public_ L Other ❑ Delta Type of Casing - Ljlrriga'tion:' Approx. ❑ Eastern Cathodic Protection Depth Specifications 17 �>- Depth of Grout Seal Geophysical LJ Other Type of Grout Surface Seal Installed by Repair Work Done FJ Type of Pump N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTRLLATION�RLPAIR/AITION LJ (No septic tank qr seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Reside ce _ Other Number of living units: Number of bedrooms _ Lot size Jp Character of soil to a depth of 3 feet: Water table depth Lo Q (� SEPTIC TANK Fj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal y SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No, & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS,,. 1� Depth Size _ r Number SUMPS Distance- to nearest: Well Foundation to "Property Cine 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 tYie SanRJoaquin 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 suchmanneras 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 applicait must call r 11 required inspections. Complete drawing n verse side. 4t- Signed X iLTitle: / ' Date:" FOR DEPARTMENT USE ONLY Appation Accepted by = Area ElStk 466-6781 Additional Oomments: X Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie to: Enviro mental Health Permit/Services 1601 E, 4azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO -7 EH 13-24 REV. 10/82 10/82 500 14-26