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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT f 1601 E. HAZELTON AVE., .STOCKTON, CA PERMIT NO Telephone (209) 466-6781 _a4:1-2,71 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDj" ,, (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 S n Joaquin Local Health District. Job Address Subdivision Name - Owner's Name Address Phone Contractor's Name `� License No, >2 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia. of Well Excavation �C ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other. Delta LjIrrigationType of Casing Depth ❑ Eastern Specifications Z Cathodic Protection P ❑Geophysical Depth of Grout-Seal Other Type of Grout Surface Seal Installed by �r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [—IWell Diameter Sealing Material (top 50') Depth Filler Material (BeTow 50') 1 TYPE OF SEPTIC WORK: NEW.INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is i / ova 11 ble within 200 feet.) n Installation will serve: Residence ` Commercial Other _-ate/ff � • SI Number of living units: E Number of bedrooms _ -7 Lot size T Character of soil to a dept of 3 feet: � w - Water table depth Xv/_41— SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lines 1 — 40/L,1— Total length/size FILTER BED ❑ Distance to nearest: Well />p Foundation 1Ok.1- Property Line SEEPAGE PITS Depth _ Size Number v2/ SUMPS Distance to nearest: Well /*6& Foundation _LP 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 appTicant t call for all equired inspections. Complete drawi on reverse si Signed X � Title: Date: / FOR D PARTMENT USE ONLY Application Accepted by Area ❑ Stk 466-fi781 Additional Comments: Lodi 369-3621 Lj�_or Grout Inspection by Date El Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental H lth Permit/Services 1601 Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFOLA ! ' S EH 13-24 REV. 10/82 10/82 500 14-26