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L✓ ( � l 4 �r APPLICATION FOR PERMIT ,, Ani j SAN JOAQLI„' LOCAL HFALTH DISIRICT ��-7 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. $ L�S Telephone (299) 466-6781 IM DATE ISSUED '$ i PERMIT EXP,IRE$ 1 YEAR fROP1 DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Loca'h Health District for a permit to construct and/or install the work herein described. This application is made in compliancewithSan Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin cal Health District. Job Addressubdivisior Name J< Owner's Name Address PhanS Contractor's Name I e No. phone 7 E TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ 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 Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation h ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing . { Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth [1 Depth of Grout Seal p{� ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump HSP, State Work Done Well Destruction U Well Diameter 50ealing Material (top 50') — Depth Filler Material (Below 50') h � f TYPE OF SEPTIC WORK: NEW INSTALLATION F1REPAIFR/ADDITION sl yl {(No septic tank or seepage pit permitted if public sewer is [ / 11available within 200 feet.) Installation will serve: Residence F/ Comm�rcial Other Number of living units: Number of bed0ooms Lot size C/LQ/1 Character of soil to a depth of 3 feet: - Water table depth f C� I� SEPTIC TANK ❑ Type/Mfg IM Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ �M LEACHING LINE No. & Length of lines �. o—tal length/size FILTER BED Distance to nearest: Well _ Foundation = — Property Line SEEPAGE PITS Depth Size Number SUMPS L1 Distance to ares t: Well 6 FoundationJ !�_ Property Line DISPOSAL PONDS ❑ • 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. I 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 person1�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 applicant must call for all required ins ectrawing o r ver�ions. Complete dside. f� Date: f Signed X/J/1� n�� ,/� /.� Title: _ FOR DEPARTMENT USE nY f ❑ Stk 466-6781 Application Accepted by Rrea Additional Comments: IM Lodi 369-3621 Pit or Grout Inspectio�by IM. Date ❑ Manteca 823-7104 Fi al Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental alth Permit/Services 1601 E. Hazelton Ave. 0. Box 2009, 5t k., CA 95201 J� FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO i �P LA 10/82 500 EH 13--24 REV. 10/82 14-26