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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ``r Telephone (209) 466-6781 7 I DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 cA the 5an Joaquin Local Health District. Job Address Subdivision Name Owner's Name Address- f G' Phone 7A Contractor's trame License No. �:S-17 2/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 00 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial F❑ Open Bottom Manteca Dia. of Well Excavation u Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing ❑public D Other ❑ Delta Type of Casing Ljlrrigatian Approx. []Eastern Specifications 71 Cathodic Protection Depth EJ Geophysical Depth of Grout Seal U Dther Type of Grout Surface Seal Installed by � Repair Work Done ❑ Type of Pump H.P. `State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') {I TYPE-OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION �No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation vii,-Il serve: Residence Commercial _ Other Number of living units: -t— Number of bedrooms Lot size Character oil to a depth of 3 feet: - �-0*A- � - Water table depth � ) SEPTIC TANK Type/Mfg / Capacity (3?7 No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines 3 146 a Total length/size / ZO 9 FILTER BED ❑ Distance to nearest: Well O Foundation Q Property Linea SEEPAGE PITS Depth Size 310 Number r SUMPS ❑ Distance to nearest: Well j 30' Foundation /0i i Property Line 2� f 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 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',,4emplol persons subject to workman's compensation laws of California." The applic m t c for 1 e ired inspect,#ors. Complete drawing on reverse side. y Signed X �- „Title:. Date: �� ✓ FOR DEPARTMENT USE ONLY Application Accepted by Areai--- ❑ Stk 466-5781 Additional Comments: dLodi 369-3621 j Pit or Grout Inspection b Date Manteca 823-7104 II Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Bax 20D9, Stk., CA 95201 i -71 FFEEBASE D AMOUNT DUE AMOUNT REMITTERECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 10/82 500 14-26