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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AN 2 P 1983 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 Rth jOAQUNj LOCAL DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUE€JEAL 14 DISTRICT (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 Nn. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab Address 3 • Subdivision Name Owner's Name Address Phone Contractor's Name ! License No. =-IL, Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION-, 1.1. AGRICULTURE WELL.,.—. -- OTHER WELL ,. PITS/SUMPS [I{� INTENDED USE TYPE OF WELL ROBLEM AREA CONSTRUCTION SPECIFICATIONS 1�— 1iD Industrial U Open Bottom Manteca Dia. of Well Excavation y U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public , OtherE Delta Type of Casing LJ Irrigation Approx. Eastern Specifications Dept ❑ Cathodic Protection fi Depth of Grout Seal Geophysical Type of Grout Other LJ Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done Well Destruction F-1 Weii Diameter, Sealing Material (top 501) Depth Filler Material (Below 50') 7ir'fn, , oo'REPAIR/ADDITION ED septic tank or seepage pit permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLAT14 { y available within 200 feet.) Installation will serve:`Residence*o'*'r Commercial _ Other i.. — �� j �• Number of living units: Number of bedrooms _rLot size S Character of soil to a depth of 3 feet: �" f p}IL� i 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 . r DESTRUCTION I LEACHING LINE LA__0'No. & Length of lines •"i' __ Total length/size FILTER BED Distance to.,nearest: Well, • t IFoundation Property Line SEEPAGE PITS Depth Size. ' ��. _ Number SUMPS U Distance to'nearest: Well. i 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 workmanis 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 applican ust call fop,—ell required inspections. -Complete drawing on reverse side" •� j Signed X Title: Date:n 6—1./ 49 TME SE ONLY Application Accepte y Area Stk 466-6781 Additional Comments Lodi 369-3621 Pit or Grout Inspection b V Date [�] Manteca 823-7104 Final Inspection by Date ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave_ P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT^E� PERM�IT(�NO. ' � � /► v� l0 �� U� � EH 13-24 REV, 10/82 (Vj .{ �� 10/82 500 14-26 ��1�r f .