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e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTTelephone AVE., 66-678STOCKTON, CA PERMIT NO. '7 -�-jJ-3 ��, LJ Telephone (209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 3- 9 (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 L cal Hea District, Job Address ►r[�1�Q d� ubdivision Name Owner's Name Address •-• Contractor's Name Phone Y Q�lS ense No. Phone ..317-Zo TYPE OF WELL/PUMP WORK: NE4! WELL R' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL --- OTHER WELL ' ►J + pITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation PIG-estic/Private ravel PackTrac 17 PubTic ❑ y Dia. of Well Casing ❑Other _ ❑Delta ❑ Irrigation Approx. Eastern Type of Casing ,�'G ❑Cathodic Protection Depth Specificationsa J ❑Geophysical Depth of Grout Seal �- ❑Other Type of Grout Repair Work Done Surface Seal Installed byjf�� ❑ Type of Pump H.P. State Work Done ►V Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) y TYPE OF SEPTIC WORK:' NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if ' public sewer is Installation will serve: Residence — Commercial _ Other available within 200 feet.) Number of living units-. Number of bedrooms Lot size Character of soil to a depth of,.3 feet: Water table depth f SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line " DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED : Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number -d SUMPS U Distance to nearest: Well Foundation Property Line I��1 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 workmant compensation laws of California." Contractor's hiring or sob-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 .call for all required inspections. Complete drawing on reverse side. Signed X Title: (� Date D ARTMENT USE Y 3 Application Accept by Area 1z- �y❑ Stk 466-6781 Additional Commen s: � ' Lodi 369-3621 Pit or Grout Inspection by Date r L-:] Manteca 823-7104 Final Inspectio'n by Date 1 6 1 A"I/], L7 Tracy 835-6385 Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Avg, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE P(RMIT N0. INFO EH 13-24 REV. 10/82 14-26 10/82 500