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APPLICATION FOR PERMIT SAN JOAQLIN LOCAL HEALTH -DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO, 73- `p 3 DATE ISSUED 3 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 th San Joaquin Local Health District. Job Address /�f Q 0 Subdivision Name Owner's Name dress % J� D / a �` Phone Contractor's Name 0/ License No, ,/� 23 % 3 Phone 6 �3 TYPE OF WELL/PUMP WORK: NEW WELL DISTANCE TO NEAREST PUMP INSTALLATION SEPTIC TANK FOUNDATION WELL REPLACEMENT ❑ DESTRUCTION ❑ SYSTEM REPAIR LJ OTHER U _ SEWER LINES DISPOSAL FED. AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA I� Industrial U Open Bottom Manteca Domestic/Private Gravel Pack Tracy 1 1 Public 0th D 1t CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia, of Well Casing PROP. LINE PITS/SUMPS L__J er ❑ e a Type of Casing Lj Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications ____ _ Depth of Grout Seal Geophysical Type of Grout Other �� """ ��--- Surface Seal Installed by Repair Work Done ' Type of Pump N.P. State Work Done P1_4R, � /ICE-- Well Destruction U Well Diamete Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPJIC WORK: NEW INSTALLATION U REPAIR/,ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feetJ Installation will serve: Residence _ Commercial Number iof living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Other Lot size Capacity Capacity Foundation Water table depth No. Compartments Method of Disposal Property Line LEACHING LINE L- No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Lire SEEPAGE PITS F-1 Depth Size _ Number SUMPS L1 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 permit is issued, I shall not employ any person in such manner as to become subject to workmank compensation laws of California." Contractor's hiring or sub -contracting signature certifies the followinq: "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 applic ust all f required ii pections. Complet in on reverse side. Signed X _Title: Date: FOR DEP TMENT USE ONLYe7 Application Accepted by /K Area Stk. 466-6781 Additional Comments: _Lodi 369-3621 Pit or Grout Inspection by Date / �Y Manteca 823-7104 , Final Inspection by �*-� Date 9 _/y' p' L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE INFO — r� . I - - AMOUNT REMITTED RECEIVED BY DATE f PERMIT NO. a ■ 111I MEN EH 13-24 REV. 10/82 10/82 500 14-26 0