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APPLICATION FOR PERMIT SAN JOAQUi"I LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE':, STOCKTON, CA, PERMIT NO, Telephone (209) 465-678I 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. 544 for sewage or No. 1862 for well/pump and the Rules and Regulations of he S�p Joaquin Local Health District. Job Address " _77- Subdivision Name Owner's Name Address Phone Contractor's Name Z11 License No. Z Phone TYPE OF WELL/PUMP 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 W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia, of Well Excavation rp F-1 Domestic/Private Gravel Pack Tracy Dia. of Well Casing V' ❑ Public Other Del to `I l Type of Casing F, Irrigation Approx. Eastern Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical ❑ Type of Grout Other 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 LJ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.)- Number of living units: Number of bedrooms _ Lot size _ GrL+c4- Character of soil to a depth of 3 feet: 16 4wiLl, Water table depth _J tiot, SEPTIC TANK Type/Mfg e1J]Le� _/yy Capacity & _ No. Compartments _ ^ PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well p FoundationProperty Line s� DESTRUCTION ❑ - LEACHING LINE No. & Length of lines �� f. 0[„t- Total length/size G FILTER BED Distance to nearest: Well Foundation roperty Line SEEPAGE PITS Depth Size Number SUMPS U Distance to nearest: Well -4MI --Foundation �T roperty Line DISPOSAL PONDS D ��I 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 applicant,�rp�t call for all firedinspections. Complete drawing on reverse side. Signed K ./L� p�G4� Title: Date: .r 9 Application Accepted by FPARTMENT USE ON YArea a_> µ E3 Stk 466-6781 A S tional Comments: Lodi 369-3621 Pior Grout Inspection by Date Manteca 823-7104 Final Inspection by Date / Tracy 835-6385 Applicant - Return all copies to: Environment Health Permit/Services 1601 E. Hazelton ! , P.O. Box 2009, Stk., CA 95201 e FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Nb �_1b SIf — e&] f Eli 13-24 REV. 10/82 10/82 500 14-26