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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 r DATE ISSUED 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 andRegulationsRegulations�of the an Joaqui cal Health District. Job Address ! Subdivision Name ) Owner's Name 'Address c�1 Phon CO S Contractor's Na Ch License No.- (a Phone Cn / TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑Manteca Dia. of Well Excavation t-1 Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public FJ Other ❑ Delta U Irrigation Approx. Eastern Type of Casing —Specifications Protection Depth ~- Depth of Grout Seal Geophysical Type of Grout L Other Surface Seal Installed by Repair Work Done Q Type of Pump H.P. State-Work Done Well Destruction U 'Well Diameter Sealing Material (top 50') Depth Fill.er Material (Below 50') --) f TYPE�OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 7j---(,No' septic tank or seepage pit permitted if public sewer is available within 200 feet.) -Installation will serve: R silence r-' Commercial _ Other- : ther Number of l iving_,units; Numtier of b Brooms Lot size —7 / Character of soil to a depth of 3 feet: rn Water table depth _ 0 SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. . ._ _Type/Mfg -Capacity-,---. _ Method of-Disposal Distance to nearest: Well a Foundation Property Line LEACHING LINE No. & Length of lines — V-i2r Total length/size �' FILTER BED Distance to nearest: Well f22 Foundation 10 Property Line S SEEPAGE PITSDepth l Size .3 NumbeI / SUMPS jJ Distance to nearest: Well d� Foundation 117 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant m st call al required inspections. Complete drawing n everse side. Signed X ,�PiC Title: _ `� T Date: FOR DEPARTMENT USE ONLY Applic ion Accepted bye Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by A Date Manteca 823-7104- Final Inspection by Date Tracy 835-6385 Applicant - Return all copies t : Environ ental Health Permit/Services 1601 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 i