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APPLICATION FOR PERMIT SAN JOAQLiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Health District, Job Address . � T 7 7 / i Ir T � Subdivision Name r tv a-f ' Owner's Name dress - � /Ai `5 Ph One { �} �j Contractor's 43we&e No. 'Z,< 3 Phone �']�[�i"3 Vf 7 TYPE Of WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FCUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial lZ&"F"" Bottom ❑ Manteca Dia. of Well Excavation estic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public C1 Other ❑ Del to Type of Casing r@ 7!�,4► {_jlrrigation Approx. [-] Eastern Cathodic Protection Depth Specifications ❑ Depth of Grout Seal ❑Geophysical Type of Grout j�Other Surface Seal Installed by Repair Work Done ❑ Type of Pumps N.P. State Work Done 1 Well Destruction U Well Diameter Sealing Material (top 50') _ ! Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) J , 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 E❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ - SEEPAGE PITS ❑ Depth Size Number SUMPS F1Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 applicant must c 11 for all required in pec tions. Complete drawing on reverse side. Signed X - Title: �_ Date 0 D PRRTMENT USE ONLY Application Accepted by Area o ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by T I h!U Date k❑ Manteca 823-7104 a Final Inspection by -7 ie Date 7-1/ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO I coS , . $ EH 13-24 REV. 10/82 10/82 500 - 14-26