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APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. b J—1-3 Telephone (209) 466-6781 � �� tq PERMIT EXPIRES 1 YEAR DATE ISSUED FROM-DATE ISSUED I - ' (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.Joa uin Local Health, District." Job Address di ian.Name Owner's Name Address Phone C Contractor's.Name License No. 2 Phone - F-'7 I TYPE OF WELL/PUMP WORK:. WELL REPLACEMENT DESTRUCTION ['J PUMP INSTALLATION'; SYSTEM REPAIR Cl OTHER DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL €" OTHER WELL PITS/SUMPS INTENDED USE TYPE OF�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 17 Industrial ❑Open"'Bottom ❑ Manteca Dia. of Well Excavation p l Domestic/Private� ❑Gravel Pack Tracy - f Dia. of Well Casing Public �j Other Delta Type ype of Casing j] Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal Geophysical E ._ .- Type of Grout Other Surface.Seal.Insta_lied by I Repair Work Done Type of Pump ' H.P. State Work Done Well Destruction ] WelI -Oiameter -- ._Sealing Material (top 50') Depth Filler Material (Below 501) i. TYPE OF SEPTIC WORK: NEW INSTALLATION J] REPAIR/ADDITION U (No septic tank.or seepage pit permitted if public sewer is o 4 , -- available within 200 feet.) v Installation{will serve: Residence - Commercial _ Other' Number c Number of{living units: Number�of:bedrooms�. Lot size'' �' _41 Character of soil to a depth of 3 feet: t, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal c Distance to nearest:' Well Foundation Property Line l ' LEACHING LINE U No.'"& Length of lines Total length/size a FILTER BED ED Distance to nearest: Well Foundation Property Line v` 1 SEEPAGE PITS be'pth"-- "" size Number j SUMPS U Distance to nearest: Well Foundation Property Line r 'DISPOSAL PONDS 7 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 r permit is issued, I shall not employ any person in such manner as to became subject to workmanb 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 t call f r al] equired in pec tons. Complete drawing on reverse side. / Signed X � �� Title�~ 4�f" Date.G -�� FOR PARTMENT USE ONLY Application Accepted by Area e9 -7 E] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 623-7104 Final Inspection byDate �! A ❑ Tracy 835-6385- Applicant Return all copies to: Environ al Health Permit/Services 1601 E. Hazelton Ave,. P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ff jDATE PERMIT NO.. } INFO IV— t 36 I EH 13-24 REV. 10/82 �j 10/B2 500 14-26 i r