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S APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTR 1601 E. HAZELTON AVE., STOCKTON, �` PERMIT N0. � ` I Telephone (209) 466-6781 " �.a:, DATE ISSUED .� E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 (Complete in Triplicate)` SAN ►! ,�% &cTI ICI "Application is hereby made to thei San Joaquin Local Health District for a permit t"dk -Ali 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 S G , Subdivision Name f Address 01 Owner's Name Phone- Phone Contractor's Name :! License No. G � $ TYPE OF WELL/PUMP WORK: NEW WELL 1:1 OTHER REPLACEMENT /DESTRUCTION ❑ �} i PUMP INSTALLATION ❑ SYSTEM REPAIR INSTALLATION ❑ SYSTEM REPAIR JJ/ OTHER L} PROP. LINE r DISTANCE TO NEAREST: SEPTIC TANK j SEWER LINES DISPOSAL FLD. PITS/SUMPS ^�- FOUNDATION AGRICULTURE WELL OTHER 14ELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIbN SPECIFICATIONS —1_ Open_Bottom""�-Q-MariteCa" Dia. of Well Excavation Industrial _ _ _ -U`' ! ` U Domestic/Private ❑Gravel Pack []Tracy Dia. of Well Casing I ❑ P lic ❑Other Delta � ❑ Type of Casing V Irrigation '� Approx."- Q Eastern Specifications ' ❑Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump h.P, ` State Work Dane — Well Diameter Sealing Material (top 50') a' Well DestructionF-1 Depth Filler Material (Below 50') " TYPE OF SEPTIC WORK: NEW INSTALLATION El ❑ (No septic tank or seepage pit permitted if public sewer is ;t available within 200 feet.) �} Installation will serve: Residence _ Commercial Other Number of living units: '1 Number of bedrooms Lot size Water table depth Character of soil to a depth of 3 feet: No. Compartments t SEPTIC TANK Type/Mfg Capacity [—I Capacity Property Method of Disposal PKG. TREATMENT PLT. ❑ Type%Mfg G Foundation Property Line SEWAGE SYSTEM ❑ Distance to nearest: Well DESTRUCTION No. &'Len th of lines " Total length/size LEACHING LINE ❑ I 9 ) FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1. s SEEPAGE PITS ❑ Depth Size Number rFoundation Property Line__.. s.. SUMPS ❑ Distance to nearest:- Well DISPOSAL PONDS ❑ will be done in accordance with San Joaquin county I hereby certify that I have prepared this application and that the work ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ti 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 1s 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 call for all required inspections. Complete drawing on reverse side. Title: Date: Signed X DEPARTMENT-USE ONLY ❑ Stk 466-6781 Application Accepted by ( Area �_� Lodi 369-3621 Additional Comments: Date ❑ Manteca 823-7104 Pit or Grout Inspection by Date �� Tracy 835-6385 Final inspection by Applicant - Return all copieslto; Environ tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2049, St k., CA 95201 RECEIVED BY DATE PERMIT NO. E FEE BASE AMOUNT DUE AMOUNT .REMITTED -33_y l � INFO ;. 10/82 500 EH 13-24 REV. 10/82 F 14-26