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' w APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED g vZ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or'insta7l 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 Owner's Name. AddressPhone Contractor's Name License No.- .r., Phone 0000 AV_ Li' W TYPE OF WELL/PUMP WORK: NEW#WELL WELL REPLACEMENT DESTRUCTION I PUMP INSTALLATION F0 SYSTEM REPAIR01 OTHER ❑ _ 0 DISTANCE TO NEAREST: SEPTIC TANK AnOL7t SEWER LINES DISPOSAL FLD. PROP. LINE d FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,/an INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open}Bottom Manteca Dia, of Well Excavation XAomestic/Private [Gravel Pack Tracy Dia, of Well Casing Public Y r Othe �j Delta V Irrigation Type of Casing �� G g Approx. Eastern Specifications ❑Cathodic Protection Depth P ❑ Geophysical Depth of Grout Seal ❑Other Type of Grout a!", Surface Seal Installed by Repair Work Dane ❑ Type of Pump H.P. 1 _ State Work Done Well Destruction U Well Diameters Sealing Material (top 501) Depth i Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION j REPAIR/ADDITION . {No septic tank or seepage pit permitted if public sewer is I 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 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 ❑ g p y LEACHING LINE U No. & Length of:lines Total length/size - FILTER BED Distance to nearest: Well Foundation v Property Line SEEPAGE PITS Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS k f 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 applicant must ca 1 for all required inspections. Complete drawing on reverse side. ! Signed X Title: /jam' Date: } FOR DEP RTMENT.USE ONLY } Application Accepted by Area - Stk 466-6781 Additional Comments: # L] Lodi 369-3621 Pit or Grout Inspection Date ! Manteca 823-7104 # Final Inspection by Date -: _S R� L Tracy 835-6385 Applicant - Return all copies to: . Envir nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 1)0 � EH 13-24 REV. 10/82 - Tia e�r� J4-1 U(, 10182 500 2 IV6l h 1-17-0 r / � "r�r+s�bsJ-r— eg—g