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APPLICATION FOR,PERMiT SAN JOAQULN LOCAL HEALTH DISTRICT i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 GATE ISSUED Q Z PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c� (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 madelin compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump J i and the Rules and Regulations of th';San Joaaui Local Health District. y Job Address Subdiilvision Nam v" Owner's Name _ dress / Phone' - Contractor's Name License No. Phone F� TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK M1 SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION { AGRICULTURE WELL OTHER WELL PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FI Industrial ❑ Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack [} Tracy Dia. of Well Casing Public ❑ Other ❑ Delta Type of Casing u Irrigation A prox. Eastern J g P ❑ Specifications Cathodic Protection [� Depth Depth of 'Grout Seal �- ❑Geophysical Type of'Grout S ❑Other Surface Seal Installed by Repair Work Done I—] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material (top 50') Depth C . Filler Material (Below.50') TYPE OF SEPTIC WORK: NEW INSTALLATION R/ADD (No septic tank or seepage pit permitted if public sewer is s LI U available within 200 feet.) Installation will serve: Residence _ ' Commercial Other Number of living units: _L Number of bedrooms i� Lot sizei2!/1� Water table depth Character of soil to a depth of 3 feet: r - Capaeity No. Compartments S SEPTIC TANK [7] Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance`to nearest: Well Foundation Property Line j DESTRUCTION ❑ _ LEACHING LINE No. & Leigth of'lines _/.___77 _.._ Total length/sizOo2_ FILTER BED ❑ Distanceto�nearest: Well -- oundation roperty Line SEEPAGE PITS epth 1-:2 Size ,2 / umber R. SUMPS Distance to Barest: Well oun tion pert 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 issu d, I shall employ persons subject`to workman;s'compensation laws of California'." The applicant call for all rin inspect-ions. Complete drawing an reverse side. /p Signed X Nyc!/C• Title: r Date: �:ey FOR DEPARTMENT USE ONL Stk 466-6781 Application Accepted by Area E Lodi 369-3621 Additional Comments: Date Manteca 823-7104 Pit or Grout Inspection � Final Inspection by Date L Tracy 835-6385 Applicant - Return all copi to: . Env ronmen 1 Health Permit/Services 160 L. (Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 'LA S .- ca 1 Z 10/82 500 EH 13-24 REV. 10/82 14-26 i