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APPLICATION FOR PERMIT SAN JOAQUi"1 LOCAL HEALTH DISTRICT -7q 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 Loca pHealth District. Job Address Glx[+ Subdivision Name Owner's Name INeT Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOl Nf)ATION ^� —T AGRICULTURE WELL ' ~OTHER WELL- _ _PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -� fD Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation U Domestic/Private FJ Gravel Pack ❑ Tracy Dia. of Well Casing L__1 Public ❑ Other E] Delta Type of Casing L, Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal L7 Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done Ef Type of Pump H.P, State Work Done Well Destruction U Well Diameter Sealing Material (top 50') ot Depth Filler Material (Below 50') CXR TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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 r Lot size fo� Character of soil to a depth of 3 feet: water table depth go SEPTIC TANK EI Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION q LEACHING LINE �f No. & Length of lines*, Total length/size FILTER BED Distance to nearest: Well _Foundation Property Line SEEPAGE PITS D Depth /S Size ��/2 Number r SUMPS F11' Distance to nearest: Well $°o Foundation 10 Property Line S DISPOSAL PONDS ED 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 workmant 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 appli a t must ca fo11 required inspections. Complete drawing on never side. r s Signed X Title: Date: TV FOR DEPARTMENT USE ONLY Appl' ation Accepted by Area Stk 466-5781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all Copies to. Envir nmen 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95261 t` FEE BASE AMOUNT DUE AMOUNT REMITTED ) RECEIVED BY DATE PERMIT NO, INFO as EH 13-24 REV. 10/82 10/82 500 14-26