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APPLICATION FOR PERMIT SAN JOAQ�IN LOCAL HEALTH DISTRICT 1601 E. 4A7ELTCN AVE., STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 3/ T PERMIT EXPIRES 1 YEAR FROM GATE ISSUED 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 Health District. Job Address o�� Vfri�� Subdivision Name Owner's Name Address Phone A14 7 0 y Contractor's Name License No. / Phone IL — TYPE OF WELL U WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR L7 OTHER U 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 II JIndustrial U Open Bottom [] Manteca Dia. of Well Excavation Domestic/Private Ej Gravel Pack Tracy Dia. of Well Casing Pubic F-1 Other Del to Irrigation Type of Casing ation LJi 9 Approx. Eastern Specifications Cathodic Protection Depth F Geophysical Depth of Grout Seal U Other Type of Grout Surface Seal Installed by Repair Work Dane Type of Pump .rt/G- H.P. 3 State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [—A (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 [7j Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ��--11 Distance to nearest: Well Foundation Property Line DESTRUCTION t_1 LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Y SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q i •� 1 O IYi YI Yw1�1�1�1�Yg41� -i�in4niY1 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 workmant 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 ust ca],?#)for all required inspections. Complete drawing on reverse side. Signed K l/.rJ� le: Date: FpR DE MEN U NLy App cation Accepted by frµ ea 5tk 466-6781 Additional Comments: ` Lodi 369-3621 Pit or Grout Inspection b Date Manteca 823-7104 Final Inspection by �. & �__ Date �--�r�Jp —Q�� Tracy 835-6385 1 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO S G o �(` --ASt, EH 13-24 REV. 10/82 10/82 500 14-26