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APPLICATION FOR PERMIT { SAN JOAQUiN LOCAL HEALTH DISTRICT t" 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Com lete in T - 1' PERMIT NO. DATE ISSUED P rip icate) 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 Re ulatio s of the. San Joaquin Local Health District. Job Address Subdivision Nam Owner's Name Address /�SlS1.-TNjl�p pP Contractor's Name -'1') License Now I Phone — TYPE OF WELL/PUMP WORK: NEW WELL IWELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES 4 DISPOSAL FLD- FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA Industrial U Open Bottom Manteca Domestic/Private E] Gravel Pack ❑ Tracy _ 17 Pub] is' �j Other F7 Delta CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation _ Dia. of Well Casing PROP. LINE PITS/SUMPS V Irrigation Fr Approx. Eastern Type of Casing [Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal LJ Other Type of Grout { Surface Seal Installed by Repair Work Done Type of Pump H.P. 11P State Work Done Well Destruction U Well Diameter i Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: t Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of .soil to a depth, of,3 feet: Water table depth SEPTIC TANK U Type/Mfg u Capacity _" -^ No- Compartmen-ts PKG. TREATMENT PLT. Type/Mfg ' Capacity Method of Disposal SEWAGE SYSTEM DESTRUCTION Distance to nearest: Well Foundation Property Lire LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS [j Depth I Size Number SUMPS L_1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C� 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 applic m st c or all equir insp c o ons. CompletAdrin, on reverse side. Signed X Title: Date: 11 V r- Application Accepted by I Additional Comments: _ 4t*W— Pit or Grout Inspection h .)_,0 final Inspection by Applicant - Return all copies to FEE I BASE INFO EH 13-24 REV, 10/82 14-26 Area C/ Stk 466-6781 Lodi 369-3621 r!T!n—- � Manteca 823-7104 Date _ _QI� �j Tracy 835-6385 Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 10/82 500 95201