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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 DATE ISSUED a� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.�� [ R r Q +� (Complete in Triplicate) 1.' VJ1 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 Sann Joaquin Local Health District. Job Address Subdivision Name Owner's Nam ddress ll! Phone 2,S79 3 3 7 7 Contractor's Name r License No. 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial A Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other [] Delta Type of Casing Irrigation :Vt)f Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal ❑Geophysical Type of Grout ^^ ❑Other Surface Seal Installed by cr- Repair Work Done ❑ Type of Pump_ H.P. I State Work Done Well Destruction ❑ Well Diameter /' Sealing Material (top 50') r"Z Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (❑ REPAIR/ADDITION ❑ (No septic tank or seepage pitpermitted is avaflable ifpublic thin ZOOfsewe)is 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 �- SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size 777111�� FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS f-1DepthSize Number SUMPS LI 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 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." L The applican must c 1 for all required inspections. Complete drawing on reverse side. Signed K Title: ', Date: =DEPRTMENTSE ONLY A cation Accep ed by Area {/ ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copse to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FINFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. 10/82 500 EH 13-24 REV. 10/82 14-26