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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH', DISTRICT 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) g 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 g.uiations of the San Joaquin Local Health District. Job Address Subdivision,Name Owner's Name Address �7 Phone C Contractor's NameA—t� License No. "lam Phone y] o Qd TYPE OF WELL/PUMP WORK: " NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (�`► PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, El1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LLINES DISPOSALFLD PROP. LINE f ~FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f ' INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation F—IDomestic/Private Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑Other [] De'ta Type of Casing Irrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth y Depth of Grout Seal ❑Geophysical r Type of Grout Other Surface-Seal Installed by Repair Work Done E] Type of Pump State.Work Done Well Destruction ❑ Well Diameter Sealing Material {tap 50'} V Depth Filler Material (Below 501 e TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION{No septic tank or seepage pit permitted if public sewer is available within 200 feet.} Installation will serve: Residence _ Gommercial �� Other_ Number of living units: -12-- Number of bedrooms „..L_ Lot size Character of soil to a depth of 3 feet: Water table depth V SEPTIC TANK Type/Mfg C Capacity _J6 � No. Compartments ❑ Type/Mfg Capacity Method of.Disposal PKG. TREATMENT PLT. . SEWAGE SYSTEM Distance to nearest: Wel] F undatti Property L' e DESTRUCTION Dc /C E �✓� r`Q"� fMp '� �� LEACHING LINE ❑ No. & Length of lines Totalwlength/•size " FILTER BED ❑ Distance to nearest: Well Foundation Property-Line- SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation: Property Line DISPOSAL. PONDS ❑ i a ; 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 workmans 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 permit is issu I shall em Ploy persons subject to workman's compensation laws of California." t mus ca 1 or 1 qui ed inspection`s, Complete awing n rever side. ""° The app Dater Signe !. Title: D ARTMENT USE ONLY 3 Application Accepted by GC Area'8 3 �> ❑ 5tk 466-6181 Additional Comments: ❑ Lodi 369-3621 k Pit or Grout Inspect95o: Date LJ Manteca 823-7104 r Final Inspection by I Date ❑ Tracy 835-6385 Applicant - Return all copi Environmental Helth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 I FEE BASE AMOUNT DUE AMOUNT, REMITTED RECEIVED 8Y DATE PERMIT NO. - - o INFO C U 10/82 500 FH 13-24 REV. 10/82 14-26 CO 4�l L,._ c� fQ