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APPLICATION FOR PER1117 SAN JOAQLi'� LOCA.. HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 �7 DATE ISSUED 6 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 iOrdinance No 549 f9r ewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local.Health District. �psC �{ p/✓ Sob Address Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER 1J" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,, PROP. LINE _} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �cw J Industrial U Open Bottom [� Manteca 4 Dia, of Well Excavation 0 Domestic/Private ❑ Gravel Pack U Tracy Dia. of Well Casing El Public _.. _ [-1Other Delta Type of Casing Irrigation Approx. [] Eastern Cathodic Protection Depth Specifications Depth of Grout Seal ❑ Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done F—J Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/.ADDITION ❑ (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: —I— Number of bedrooms - Lot size Character of soil to a depth of 3 feet: O _ _-- Water table depth SEPTIC TANK Type/Mfg b Ctr Capacity No. Compartments T r� PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well -Foundation. Property Line DESTRUCTION LEACHING LINE IFJ -No. & Length of lines S Total length/size FILTER BED . Distance to nearest: Well Foundation Property Line SEEPAGE PITSDepth Size Number + SUMPS Distance to nearest: Well Foundation Property Line 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 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 wcrkman� compensation laws of California." ractor's hiring or sub-contr ting signature certifies the following: "I certify.that in the performance of the work for which his it is issued I shall a loy persons subject to workman's compensation laws of California." The applican u t c o 1 u'r ections. Complete dr 3ng on r verse sib f_ Signe Title: Date: MENT USE ONLY Application Accepted by Area G Stk 466-6781 Additional Comments: [� Lodi 369-3621 Pit or Grout Inspection by Datei/ I ] Manteca 823.7104 Final Inspection by T Date if ? ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BRSE AMOUNT OUE AMOUNT REMITTED RECEIVED I DATE PERMIT NO. INFO LH 13-24 REV. 10/82V � 10/82 500 14-2b