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r APPLICATION FOR PERMIT SAN JOAQUid� LOCAL '-rTZLTH DISTRICT J� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209).466-6781 DATE ISSUED PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) CA Application is hereby made to the San Joaquin Local health 'District for a permit' to construct and/or install the work herein [la described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump l and the Rules and Regul tions of t e an ,J aquin Local Health District. UJ Jab Address Fi Subdivision,Name n; Owner's Name Films' Address Phone Co tractor's Name ` � L�License No. �� Prone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT,❑ ' -OES3RUCT-ION PUMP INSTALLATION ❑ SYSTEM REPAIR �� "� OTHER L� 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 IJ Industrial U Open Bottom C1 Manteca Ria, of Well Excavation i U Domestic/Private D.Gravel Pack ❑Tracy Oia, of Well Casing_ ❑ Public ❑Other ❑ Delta Type of Casing Irrigation A rox. Eastern # i Li g PP ❑ Specifications Cathodic Protection DepDepth Depth of Grout Seal ❑Geophysical Type ofjGroutf!r Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P., State Work Done Well Destruction ❑ Well Diameter # 5eaing:Materiall(top 50') , Depth Filler'Material (Below 50'.) .„ TYPE OF SEPTIC WORK: NEW INSTALLATION U { REPAIR/ADDITION (NoIseptic tank or seepage pit permitted if public sewer is 6 available within 200 feet.) �y Installation will serve: Residence T Commercial Other p f Number of living units; t .; Number of bedroomsr�� Lot size �� Character of soil to a depth of 3 feet: !�T� i Water table depth SEPTIC TANK ❑ Type/MfgCapacity z No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg t Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation; #Property Line DESTRUCTION LEACHING LINE No. & Length of lines `""; Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ] Depth Size 322 ► __ Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F ; *. .I hereby certify that I have prepared this application•'and that the work wi W 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 suchsmanner 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 is it t this is ed, I s 11 employ persons subject to workman's compensation laws of California." The applic ust al fo 1 e red inspections. Complete'drawing reverse side. Signe rte" _ f ` Title 4 Date ) v ,f!/ r iFF `�ilp MENT USE ONLY '0Application Accepted by Area S 7 _� JU� Stk 1 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date `/_2-8�3 ❑ Manteca 823-7104 a Date Tracy 835-6385 Final Inspection by l --- Applicant - Return all copies to: Environmental Health-Permit/Services 1601 ,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE r.BASE AMpUNT DUE AMOUNT REMITTED RECEIVED BY ATEFr PERMIT NO. .` FO ff / IN 1D/82 500. EH 13-24 REV. 10/82 14-26