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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH 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) t Application is hereby made to the San Joaquin Local Health District fora 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 ; Saw Subdivision Name. iAddress /$l LCAi Phoney Owner's Na Contractor's Name /`Q y q S License No. Phone 44 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ UJ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK! SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION + AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V I IJ Industrial Open Bottom (] Manteca Dia. of Well Excavation F-1 Domestic/Private Gravel Pack [Tracy Dia. of Well Casing F] Public Ll Other Delta Type of Casing L iIrrigation f Approx. ❑ Eastern Specifications i Depth I—I.Cathodic Protection 6 Depth of Grout Seal Geophysical t . Type of Grout L Other Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction U Well Diameter Sealing Material (top 50') — ,p Depth Filler Material (Below 50') 1Ju P TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/AD1)1TION � (No septic tank or seepage pit permitted if public sewer is J I available within 200 feet,) Installation will serve: Residence X Commercial Other # Number of living units: / Number of bedrooms Lot size I Character of soil to a depth of 3 feetWater table depth ASEPTIC TANK Type/Mfg �+ Capacity / 7,x[2 No. Compartments Method of Disposal PKG. TREATMENT PLT. Type/Mfg Capacity P 0 SEWAGE SYSTEM Distance to nearest: Well ~--- Foundation //7 -0' Property Line DESTRUCTION c. r LEACHING LINE R' No. &'Length of lines -- Q " Total length/size FILTER BED Distance to nearest: Well Foundation Property Line /© i, SEEPAGE PITS Depth+"• Size Number SUMPS L-1 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 1 permit is issued, I shall not employ any person in such manner as to become subject to workmanIs compensation laws of California." j Contractor's hi 'ng or sub-contracting signature certifies the following: "]'certify that in the performance of the work for which this permit is slued, I shall employ person subject to workman's compensation laws of California." The applica all for 1 req inpect s, Complet drawing on reverse side. I Signed X, Title: Date: E DEPARTM {•T USE ONLY Application Accepted by Area _- Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or.xGrout Inspection by Date Manteca 823-7104 I, Final Inspection by Date jJTracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. . IN + 10/82 500 EH 13-24 REV, 10/82 14-26