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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, U Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 wel3/pump and the Rules and Regulations of the S n Joaquin Lac 1 Health District. Job Address r, subdivision Name Owner's NamecD oe, Address Phone Contractor's Name License No. lr , Phone TYPE OF WELL/POMP 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 I� Industrial U Open Bottom El Manteca Dia, of Well Excavation 1 ❑ Domestic/Private ❑ Gravel Pack L] Tracy Dia. of We11 Casing ❑ Public �J Other ❑ Delta Type of Casing irrigation Approx Eastern Specifications Cathodic Protection Depth ❑Geophysical Depth of Grout Seal ❑ Other Type of Grout Surface Seal Installed by Repair Work Done Type of Pump H.P: State-Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTRLLATION U REPAIR/ADDITION U (Noyseptic�on 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 Character of soil to a depth of 3 feet: Water table depth �G SEPTIC TANK Type/Mfg Capacity (i ff No. Compartments y PKG. TREATMENT PLT.K Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well/G� Foundation - .— ------ Property Line DESTRUCTION ❑ LEACHING LINE X No. & Length of lines f Total length/size GQ f FILTER BED Distance to nearest: Well /C f Foundation Property Line SEEPAGE PITS Depth _ Size 7 r Number SUMPS Distance to nearest: Well d ff Foundation fQ - �'9f f Property Line DISPOSAL PONDS CI 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 applicantwqst ll for all re fired insp tions. Complete drawing o ersesi e. e: 7 Signed X � / TitlDate: w�- �% NT US LY Application Accepted Area Stk 466-678I Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Environ ental Health Permit/Services 1601 EA�zeltn Ave., P.O. Box 2009, Stk., CA 95201 F E BASE AMOUNT DUE AMDUNT REMITTED RECE VED BBY DATE PERMIT N0.FO EH 13-24 REV. 10/82 10/82 500 14-26 „