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APPLICATION FOR PER.-T7 ST-14 JCAQLIN LOCAL HEATH DISTRICT r 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 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 Local Health District, Job Address (� f Subdivision n Name Owner's Name Address �. � J /tijC/Ir¢a! b Phone g 6 Q &5S Contractor's Name License No. / Phone 3y TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION Lj 11" PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation 'U Domestic/Private ❑Gravel Pack [j Tracy Dia. of Well Casing 1-1 Public r-j Other Delta Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications Ej Cathodic Protection Depth Depth of Grout Seal -17 Geophysical _ T Other Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (tap 501) Depth Filler Material (Below 50') TYPE of SEPTIC WORK: NEW INSTALLATIONIR/ADDITION jJ (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: l Number of bedrooms _ Lot'size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK C1�Type/Mfg 0g, Capacity No. Compartments Z. PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM �-y Distance to nearest: Well r p Foundation -1-0 Property Line DESTRUCTION �l LEACHING LINE No. & Length of lines -3 'Total length/size �- FILTER BED Distance to nearest; Well Q r Foundation � Property Line r SEEPAGE PITS Depth Size if Number SUMPS Distance to nearest: Well Foundation _ Property Lines+_ 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 sh 1 em oy persons subject to workman's compensation laws of California." r. The applica mu call f 11 equired inspections. Complete drawing on reverse side. Signed Title: ti- Date: FOR DEPARTMENT USE ONLY Stk 466-6781 r � Application Accepted by S{ Area , Additional Comments: Lodi 369-3621 Pit or Grout Inspection b A Date Manteca 823-71D4 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o: Enviro mental Health Permit/Services 16 E. Mevn Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO A = b ' EH 13-24 REV. 10/82 10/82 500 14-26 r