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APPLICATION FOR.PERMIT j UiY l 51983 SAN JOAQUiN LOCAL HEALTH DISTRICT V Y 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 SAN JOAQUIN LOCAL DATE ISSUED HEALTH ��+'�' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 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 Hea th District. Job Address 4 ) .' +Subdivision Name Owner's Name Address ,JA 117Phone Phone Contractor's Name P��, Jt/ - License No. TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION \J PUMP INSTALLATION SYSTEM REPAIR OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U 1� hf Industrial U Open Bottom EJ Manteca Dia. of Well Excavation Domestic/Private L] Gravel Pack F� Tracy Dia. of Well Casing ❑ Public [Other Delta Type of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal D Geophysical Type of Grout Ll other Surface Seal Installed by Repair Work Done Type of'Pump 15V,9,_ H•p• c State Wark Done fW f,(.D ► Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') 4 TYPE OF SEPTIC WORK: NEW INSTALLATION f_1 REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is ��) 4 available within 200 feet.) ��'1 Installation will server Residence _ Commercial _ Other W Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth -- SEPTIC TANK El Type/Mfg Capacity No. Compartments 01 PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal' SEWAGE SYSTEM ' Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No, & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line F SEEPAGE PITS Cj Depth Size Number SUMPS U 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 L permit is issued, I shall not employ any person in such manner as to become subject to workman Is 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 sh 11 employ persons subject to workman's compensation laws of California." The applican _ ust call fo fallquired inspections. Complete drawing on reverse side. j Title: Date: _4� Signed X r p ME ONLY � � 466_6781 Application Accepted by Lodi 369-3621 Area Stk Additional Comments: Pit or Grout Inspection Date Ll Manteca 823-1104 Final Inspection by Date7_Z,� E) Tracy 835-6385 IJ,S�I Applicant - Return all copies to: Environment ealth Permit/Services 1601 E. Hazelton A{r�,, P.O. Box 2009, Stk., CA 95201 C =INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT[ fNO,r_ i5 3 Is t�t `� f, EH 13-24 REV. 10/82 IO/82 500 14-26