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APPLICATION FOR PERMIT` SAN JOAQUIN LOCAL'HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON,,-CA PERMIT NO. Telephone.(209) 466-6781= DATE ISSUED k •PERMIT EXPIRES 1 YEAR FROM DATE'- ISSUED (Complete in Triplicate) Application is hereby made to the Sa Joaquin Local Health District for a permit Jto construct and/or install the work herein described. This application is madein compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump 'and the Rules and Regulations of the San Joaquin ocal Health District. Job Address ' 3 Gh Subdivision Name Address Cl Phone Ur 77 �� Owner's Name Phone Contractor's Name License No. TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F� DESTRUCTION ❑ ' PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C 1 Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing Public Cj Other I Delta Type of Casing �1 irrigationApprox. ❑Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout 4 Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter * Sealing Material (tap 50') — Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION I (No septic tank or seepage pit permitted if public sewer is — available within 200 feet.} Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM c Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER BED E] Distance,to nearest: Well Foundation Property Line • SEEPAGE PITS El' Depth, Size Number SUMPS Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS �Q ` a �� Y �- ruck raved 1 rd ol. ' e� 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.- Nome 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 warkmath compensation laws of California."i Contractor's hiring ar 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 applic/aa �ust call for/s�11 rwired in —ections. Complete drawing on reverse side. € Signed X�!�; [ a Title: Date: I FOR DEPARTMENT USE ONLY Stk 466-6781 I Application Accepted by �.. Area EJ Lodi 369-3621 Additional Comments: 61 Date ;9' Manteca 823-7104 Pit or Grout-Inspection Date r S L Tracy 835-6385 Final Inspection byCA 95201 ,k Applicant - Return all'copi o':I Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., 1i FEE BASE AMOUNT ''!'DUE AMOUNT, REMITTED RECEIVED BY DATE PERMIT NO. INFO >-M S 5 4M 10/82 500 EN 13-24 REV. 10/82 CX-At CD\3 1 - 14-26 --