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APPLICATION FOR PERMIT 7 .3 SAN JOAQUIN LOCAL HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.�-;y S$ Telephone (209) 466-6781 GATE 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 a Regulations of the San Joaquin Local Health District. Job Address �' Subdivision Name (/ Owner's Name 5 1 Address Phone _ Contractor's Name L L License No. �_ Phone g gas" ) i TYPE OF WELL/PUMP WORK: NEW WELL WELL,REPLACEMENT DESTRUCTION PUMP INSTALLATION .❑ SYSTEM REPAIR OTHER DISTANCE-TO NEAREST.--SEPT"1"C-TANK ----SEWER-L-1-NES------"- -DISPOSAL FL-D:------ --PROP-.-k-I f- - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public ❑ Other ❑Delta Irri" aton Type._o.f-Casaag. - U g Approx. ❑ Eastern Depth Specifications ❑Cathodic Protection P Depth of Grout Seal �- ❑Geophysical Type of Grout Other Surface Seal Installed by I (] Repair Work Done 0 � Type of Pump H'.P. State Work Done N Well Destruction ❑ Well Diameter Sealing Material (top 50') _ /J Depth Filler Material (Below 50') 0 TYPE OF SEPTIC WORK: NEW INSTALLAT48N REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Ll----Commercial Other s Number of living units: Number of bedrooms _ Lot size Character of soil to a depth of 3 f t: Water table depth SEPTIC TANK Vj/Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mf Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Fun ation Property Line DESTRUCTION ❑ �. LEACHING LINE & Length.,of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS N4/-Depth Size 3 3 Number �.. SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El 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 hir' or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is is d, I shall mploy persons subject to workman's compensation laws of California." The app st�c I al equ,_ ed inspections. Complete Aawing o Sign Title: Date: s Application Accepted by FO EP ENT gyE ONLY Area Stk 466-6781 Additional Comments: IF Lodi 369-3621 Pit or Grout Inspection by Date /,4 J � ❑ Manteca 823-7104 Final Inspection by Date /o' fry ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE :�,I T NO. INFO SS EH 13-24 RE:V. 10/82 10/82 500 14-26