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~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT NO. d PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED _11�L mZ (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 Joaqu n ocal Health District. Job Address 33 N S 7�- Subdivision Name Owner's Name Address Contractor's NamePhone _ License No. � Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y PUMP INSTALLATION SYSTEM REPAIR OTHER [] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE- OF WELL PROBLEM AREA IndustrialCONSTRUCTION SPECIFICATIONS EJ Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private EJGravel Pack Trac ❑ Public y Dia. of Well Casing ❑Other E] Delta Irrigation Type of Lasing Approx. Eastern Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal ❑Other Type of Grout Repair Work Done Type of Pumpy P Surface Seal Installed by Well Diameter Well Destruction tJ State Work Done �(! Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION JJ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is W Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: SEPTIC TANK [j Type/Mfg Capacity Water table depth ^` T PKG. TREATMENT PLT. ❑ Type/Mfg No. Compartments CapacityT Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE ❑ No. & Length of lines FILTER BED Total length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS I Distance to nearest: Well Foundation DISPOSAL ANDS ❑ Property Line 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, hiring or sub issued, I shall not employ any person in suc Contractor's manner as to become subject to workman§ compensation laws of California." -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 s call f al u' a irrspe ions. Complete drawin Signed X 9 eerse side. Title: Date: FOR AR T USE ONLY Applicati Accepted by Area -^/—A,"3 ❑ Additional Comments: Stk 466-6781 Pit or Grout Inspection by 01 E] Lodi 369-3621 Date Final Inspection by 0 Manteca 823-7104 Applicant -63 - Return all copies to: Environmenta�Pemit/SericeDas e1601 Avo. P.P.O. Boxy 200935Stk85 CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT NO. EH 13-24 REV. 10/82 14-26 10/82 500