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APPLICATION FOR PERMIT SAN JOAQCiN LOCAL HEALTH DISTRICT (' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 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 Subdivision Name Owner's Name f3ci 1h /7 %ri- Address DoT" /-P-.� Sfsy J�.,,�F, iy Phone � Contractor's Name License No. /Vi/- %/ Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 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 ❑ Industrial U Open Bottom F_j Manteca Dia. of Well Excavation (� U Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public [j Other Delta Type of Casing Lj Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal (` 17 Geophysical V� Type of Grout' C Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') a Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION,{ REPAIR/ADDITION E) (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: / Number of bedrooms / Lot size 6/" r fir Character of soil to a depth of 3 feet: (/Ay 4c,4,11 Water table depth 9` SEPTIC TANK Type/Mfg `ye` <e f Capacity /P ale" No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well I-- Foundation /-1 ' Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED © Distance to nearest: Well Foundation it Property Line ' SEEPAGE PITS [-j Depth Size Number SUMPS L_1 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 workmanis 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 must call for all required inspections. Complete drawing on reverse side. // �-%1� =/ Signed X /-E-ft- Title: Date: R PARTMENT USE ONLY 7 Application Accepted by ! Area Stk 466-6781 Additional Comments: F] Lodi 369-3621 Pit or Grout Inspection by Date 17 Manteca 823-7104 Final Inspection by Date L7 Tracy 835-6385 Applicant - Return all copies to: Environmenta alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO � `. 1 F� EH 13-24 REV. 10/82 10/82 500 14-26