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AF'PLICRTION FOR PERMIT j u 271983 SAN JCAQUiN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. SAN j ,7,VLP� LOCAL Telephone (209) 466-6781 H UFI..� DISTRICT 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 Local Health District, Job Address ��t�a) �J�w.rPSubdivision Name Owner's Name - Address f�Sdd n��a � i_ Phone — � Contractor's Name License No. �. `l.��....... Phone I TYPE F WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U �(O PUMP INSTALLATION f SYSTEM REPAIR OTHER U ANCE 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 J�ustrial a U Open-Bottom ••==0 Manteca—=---= .-. -Dia.. of Well Excavation U•J Domestic/Private F-1 Gravel Pack F_J Tracy Dia. of Well Casing L7 Public F-1 Other ❑ Delta Type of Casing L, Irrigation Approx. Eastern Specifications Cathodic Protection Depth LJ Geophysical Depth of Grout Seal Type of Grout U Other Surface Seal Installed by Repair Work Done Ej Type of Pump H.P. aj„> State Work Done Pu ,rte Well Destruction U Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) �j Installation will serve: Residence _ Commercial _ Other 0" Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line DESTRUCTION44 LEACHING LINE U No. & Length of lines Total length/size 1 FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS 71 Distance to nearest: Well Foundation Property Line-- DISPOSAL ine 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." The applica t must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: r t OR DEPARTMENT USE ONLY i Application Accepted by Area Stk 466-6782 3]f Additional Comments: V Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date — Tracy 835-6385 Applicant - Return all copies to: Envi o meital Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Li S.o� 75-3--\.o C7 EH 13-24 REV. 10/82 10/82 500 14-25