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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 4� Al� ( � lff� I PERMIT NO. i �O DATE ISSUED.a 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 uiations of tte San Joaq in Local Health District. Job Address t i71JJ Subdivisi n Name Owner's Name Address /4lir Phone Contractor's Name lldv&lvaicense No. Phone ,� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx, Q Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Other Type of Grout / Surface Seal Installed�tp Repair Work Done ❑ Type of Pump,,, H.P. J State Work Done Well Destruction F-1WellDiameter Sealing Material (top 50')...ice /p wI tie - --� . Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other 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 SYSTEMDistance d to nearest: [Jell Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. S Length of lines Total lengtF/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 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 applica must c for all requir d nspections. Complete draw' g on r se si Signed K_ Title: ��?a%-�� Date: OF 2 OR EPARTMEN7 UWCNLY C� • Application Accepted by Area --� ❑ Stk 46fi-6781 7 � L Additional Comments: t5�L odi 369-3621 7 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by / �� r — Date _ / ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental H alth Permit/Services 1601 E. Haceltu Av,/ , P.O. Dox 2009, Stk., CA 95201 FEE BASE AMOUNT DUE' AMOUNT REMITTEDLW "PI RECEIVED BY A.DATE PERMIT NO. INFO. -i EH 13-24 REV. 10/82 14-26 10/82 500 I