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i APPLICATION FOR PERMIT - Ar SAN JOAQUIN LOCAL HEALTH DISTRICT 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 workherein 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/Re ulations of the San Joaquin Local Health District. Job Address a� , Owner's Name Address r,23[� W, .20>!k Q�gPhone Contractor's Name �/J_p & ,,,, icense No. _ (! _ Phone —r2 TYPE OF WELL/PUMP WORK: NEW WELL k4 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ( SEWER LINES �r, r* DISPOSAL FLD.I�O —4 PROP. LINE FOUNDATION �W AGRICULTURE WELL ,SQ 1-{' OTHER WELL PITS/SUMPS �w INTENDED USE TYPE OF WELL PROBLEM AR A CONSTRUCTION SPECIFICATION, �� Industrial ❑Open Bottom ❑Mante Dia. of Well Excavation �� Domestic/Private Gravel Pack ❑ Tra Dia. of Well Casing � Public ❑Other ❑ D to > Type of Casing C/-1 SS' LlIrrigation �6 0_ Approx. astern ,� ❑ Cathodic Protection Depth Specifications � � V Depth of Grout Seal U Geophysical Other 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') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal Septic Tank � 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 Number SUMPS U Distance to nearest: Well Foundation Property Line 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 sign a ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I all mploy ons subject to workman's compensation laws of California." The applicant st ca r req ections. Complete drawing on r verse side. Signed X Title: (L�.4 Date: lz� FOR DEPARTMENT USE ONLY 3 ! Application Accepted by Area b ❑ Stk 466-6781 Additional Comments: fV V Lodi 369-3621 Pit or Grout Inspection by Date :ktA- ❑ Manteca 823-7104 Final Inspection by Date �.� % _� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental He9fth Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �--�►3 � • g3 -3� EH 13-24 REV. 10/82 10/82 500 14-26