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APPLICATION FOR PERMIT SAN JCAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 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 and Regulations of the.SanngJoaquin Local Health District. I Job Address C7 & // ��subdivision Name Owner's Name Address lf4fO Phone Contractor's Name License No. Phone r TYPE OF WELL/PUMP WORK: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE y }# FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑.Manteca Dia. of Well Excavation Lj Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public G Other ❑ Delta Type of Casing �jIrrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth Depth of Grout Seal Geophysical Type of Grout LJ Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _State Work Done f Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') - r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DOITIO ❑ (No septic tank or seepage pit permitted if public sewer is able within.P00 feet.) Installation will serve: Residence Commercial _ Other �UutaCE ice! a � �� 1 Number of living units: Number of bedrooms Lot size R Q Character of soil to a depth of 3 feet: Water table deths't/ SEPTIC TANK [rj Type/Mfg � - Capacity /�� No. Compartments PKG. TREATMENT PLT. Type/Mfg city Method of Disposal SEWAGE SYSTEM Distance to nearest: Well�yiy ltd -found ion Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines ; Total-length/size_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Q DepthSize Iff^ Number SUMPS �I Distance to nearest: Well 2-� Foundation s Property Line (� DISPOSAL PONOS Cl� �._ f��J � � ttl2l.- fL121� I hereby certify that 1 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 far 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:111-certify that An-the performance of th.--krk for which . this permit is issued, I shall employ persons subject to workman's compensation laws-of California.' The applicant mu t call for all required inspections. Complete drawing an reverse side. ,! z ? Signed X Title: Date: FOR DEPAR ENT SE ONLY Area l E3 Stk 466-6781 Application Accepted by ' . n DD ' 3621 Additional Comments: pd It cir, f Lodi 369- Pit or Grout Inspection b Date ❑ Manteca 823-77100.104 I Final Inspection by Date ❑ Tracy 835-6385- - �... , l Applicant - Return all copie to: Environmental Health Permit/Services 160 E.. Hazelton Ave., P.O. Box 20D9, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT INFO 10/82 500 EH 13-24 REV. 10/82, 14-26