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APPLICATION FOR PERMi_T SAN JCAQLi'; LOCAs_ HEALTH 'DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 1 I O 83 R PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a 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. 49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job AddresclQ%3 er Subdivision Name Owner's Na Address Contractor's NaJ License No. 2 Phone m TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION _P-UMP INSTALLATION- r- SYSTEM-REPAIR DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l� Industrial U Open Bottom Manteca Dia. of Well Excavation IJ Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing Public Other Delta Type of Casing Li Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal LIJ Geophysical Type of Grout LJ 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') C7 TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) 03 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 EI 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 U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line r SEEPAGE PITS Depth Size Number' SUMPS 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, 1 shall not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's h" ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i i sued, I shall emplo pe ons su ect to workman's compensation laws of California. The app}ic t m t,calI 'r�.1�I re _ir nspg �ons_ te dr on-reyerse_side. Da� _ Signed X '�✓� Title: ^� FOR DEPARTMENT USE ONLY &tk 466-6781 Application Accepted by j J Area j_ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date LJ Manteca 823-7104 Final Inspection by Date �3 Tracy 835-6385 Applicant - Return all copies to: nvironmertal Health Permit/Services 1601 E. Hazelton Ave., P.0, Box 20D9, St k., CA 9520 w. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OALE �3- IT NO. INFO q tt-� � a49 10/82 500 EH 13-24 REV. 10/82 14-26