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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �SO Telephone (209) 466-6781 p DATE ISSUED S O 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 Subdivision Name �p Owner's Name Address Phone r3 d a Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ UJ yi 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 Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack [] Tracy Dia. of Well Casing 1 ❑ Public CJ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth roecDepth 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'} I TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION erjNo septic tank or seepage pit permitted if public sewer is p available within 200 feet.) Installation will serve: Residence commercial _ Other Number of living units: _� Number of bedrooms 3---- Lot size Character of soil to a depth of 3 f t: Water table depth lJ r SEPTIC TANK FJ Type/Mfg Capacity 15-11)— No. Compartments "L j PKG. TREATMENT PLT. ❑ Type/Mfg Capacity r Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Q f' Property Line 120 j DESTRUCTION U LEACHING LINE No. & Length of lines 2 �� Total length/size FILTER BED ❑ Distance to nearest: Wel l__ Foundation - 1 . Property.Line SEEPAGE PITS Depth Size q Num er 7- SUMPS Distance to nearest: We11Foundation x Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquanecounty ordinances, state laws, and rules and regulations of the San Joaquin,L"ocal ,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/ t caP4. 41 - o al required inspections. Complete drawing on reverse side. Signed X Title: Date: NET FOR DEPARTMENT USE ONLY S Application Accepted by - -Area 4__ ❑ Stk 466-6781 Additional Comments: '5i� Lodi 369-3621 Pit or Grout Inspection Date ❑ Manteca 823-7104 Final Inspection by 'Date 3 ❑ Tracy 835-6385 Applicant - Return all copie to: LE�hi�rnmeta Health Permit/Services 1601 E. Haz lton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERRMIT NO. Q 1 INFO c A� a3-9 3Q 10/82 500 EH 13-24 REV. 10/82 14-26