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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 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 Local Health District. Job Address 3 r z Lpr c ' Zx Subdivision Name Owner's Name& ! Address 0r Phone ' W Contractor's Name L cense No. Phone.2 ;:10 I TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION-' PUMP INSTALLATION (] SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r .,1 .s[3 •{ DISPOSAL FLO. �d PROP. LINE FOUNDATION _ /D rj AGRICULTURE WELL OTHER WELL PITS/SUMPS —, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation rr Domestic/Private ravel Pack ❑ Tracy Dia. of Well Casing {' Public Lj they Delta Q r Lj Irrigation 2q / DepthSpecifications Type of Casing ❑ Eastern pecifications r r a4„� Cathodic Protection P -- - - 17 Geophysical Depth of Grout Seal LJ Other Type of Grout �,C10-1 Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION [J- (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth �n 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 ❑ r�`� LEACHING LINE ❑ No. & Length of lines Total length/size Q FILTER BED Distance to nearest: Well Foundation Property Line 0 SEEPAGE PITS [j Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ID I [ hereby certify that ] 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 s' nature certifies the following: "] certify that in the performance of the work for which this permit is issued, I sha empl sons subject to workman's compensation laws of California." The appli s ca fo 1 r i d inspect' ns.- Complete drawing on reverse ,de. Signed Title: Date: d F TME E DN LY Application Accepted I Area O a E] Stk 466-6781 Additional Comments C D Lodi 369-3621 Pit or Grout Inspection b Date ` ❑ Manteca 823-7104 Final Inspection by 'exceDateOQ/ ❑ Tracy 835-63B5 Applicant - Return all copies to: Environment Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT N0. INFO J-A3 EH 13-24 REV. 10/82 _., 10/82 500 14-26