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APPLICATION FOR PERMIT "s SAN JCAQDiN LOCAL HEALTH DISTRICT ]� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. bp3 l �2 Telephone (209) 466-6781 DATE ISSUED 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) 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 mad&!in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welI/pump and the Rules and-Regulations of the�San Joaquin Local Health District. Job Address Subdivision Name Address " ti Phone Owner's Name Phone Contractor's Name License No. (- TYPE OF WELL/PUMP WORK: NEW(WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR Li OTHER L J SEWER LINES DISPOSAL FLD- PROP. LINE DISTANCE 70 NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION f AGRICULTURE WELL OTHER WELL �} 1 INTENDED USE TYPE OF WELL PROBLEM AREA i CONSTRUCTION SPECIFICATIONS .i IJ Industrial Lf OpeniBottom ❑Manteca Dia. of Well Excavation F Dia. of Well Casing Domestic/Private ❑Gravel Pack ❑Tracy { Delta ! ❑ Public ❑Other ❑ Type of Casing Irrigation Approx. ®Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal t ❑Geophysical Type of Grout 'I Seal Installed by ❑Other Surface H p• State Work Dane Repair Work Done K Type of Pump' Well Destruction ❑ Well, Diameter" (a - Sealing Material (top 50') I Depth / Filler Material (Below 509 { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit availableewithin d if u200cfeet.)sewer is Installation will serve: Residence Commercial Other Number of living units: _- YNumber of bedrooms~ Lot size. Water table depth \l ' E Character of soil to a depth of 11 3 Capacity feet: No. Compartments Capacity SEPTIC TANK ❑ Type/Mfg*; Method of Disposal PKG. TREATMENT PLT. ElType/Mfg Property Line SEWAGE SYSTEM ❑ Distanc, to nearest: Well. Foundation P y DESTRUCTION No. & Len th of lines Tota] length/size LEACHING LINE U g Pro erty Line FILTER BED 1---1 _ Distance to nearest: Well Foundation p � Number SEEPAGE PITS Depth ;� Size Property Line SUMPS l�V Distance to nearest: Well Foundation P DISPOSAL PONDS �V 1 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. Name 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 call for all required inspections. Complete drawing on reverse side. Date: 11�( = b Signed X Title: FQR A MENT USE ONLY ❑ Stk 465-578I A ication Accepted by �r/t' Area [� _._ =-�-� ❑ Lodi 369-3621 Additional Comments: Date ❑ Manteca 823-7104 Pit or Grout Inspection by Date ❑ Tracy 835-6385 Final Inspection by " Applicant - Return al o - s tb- Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 RECEIVED BY DATE PERMIT NO. FEE BASE AMOUNT,. DUE AMOUNT REMITTED INFO 10/82 500 EH 13-24 REV. 10/82 14-26