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APPLICATION FOR PERMIT w f SAN JOAQL'iN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 11YEAR 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 Jo a uin Local Health District. Job Address (�Cj S SdsVame Owner's NamerYJ Address 7 Phone Contractor's NameLf, License No. �� S Phone TYPE OF WELL/PUMP-WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �`0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ v DISTANCE TO NEAREST: SEPTIC TANK0 SEWER LINES DISPOSAL FLD. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p, INTENDED USE TYPE OF, WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation �� a Domestic/Private � ®Gravel Pack ❑ Tracy Dia.-of Well Casing ❑ Public-; ; c ❑ Other n ❑ Delta Type of Casing r ❑ Irrigation Y Approx. { ❑ Eastern Specifications Cathodic Protection Depth ❑ Depth of Grout Seal ❑Geophysical ''"'* ' Type of Grout r ir— . X ❑Other Surface Seal Installed by ,J�_ le't— Repair Work DoneE] Type of Pump — H.P. _ y State Work Done Y Well Destruction ❑ Well Diameter �r Sealing Material (top 50') t Depth . '. ygggo 4, Filler Material (Below 50')' TYPE OF SEPTIC WORK: NEW;INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is "*m.■ 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 i, PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: .Well Foundation Property Line DESTRUCTION Q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Q Distance to•nearest: Welly_ } Foundation Property Line SEEPAGE PITS W ❑ Depth . , Size I Number SUMPS ` ❑ —Distance'to'neares'fi`W611 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 iss e I, shall employ persons subject to workman's compensation laws of California." The applicant mus 11 f allrred inspections. Complete drawing or")verse side. t Signed X r �r Title:' r f� �+ Date: 3 p� i F DEPARTMENT US NLY i Application Accepted,by Area -__ ❑ 5tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by r� Date .�G ❑ Tracy 835-6386 Applicant•—Return_all-copies:tn.;..EnwS.ronmental,: alth_p_ermit/5ervices. 1601 E. HazeAve., P.O. Box 2009, Stk., CA 95201 FEE TBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3-1 0 v—1 ri /8 500 EH 13-24 REV. 10/82 14-26