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InvA k� D� j APPLIChT10N FOR HERMIT JUN 6 1984 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE. STOCKTON, CA G` SAN JOAQ€ IN LOCAL Telephone (209)'466-6781 PERMIT NO. HMTH DISTRICT PERMIT EXPIRES I YEAR'FROM DATE'ISSUED r DATE ISSUED--� rt (Complete in Triplicate) k Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1662 for well and the Rules.and Regulations of the-San Joaquin Local Health District. herein f Job Address /pump l �I I " Subdivision Name Owner's Name �.: Contractor's Named Address r �� License No. Phone Phone /ye TYPE OF WELL/PUMP WORK: NEW'WELL Q WELL REPLACEMENT 0 PUMP INSTALLATION ❑ DESTRUCTION ❑ "'� SYSTEM REPAIR w DISTANCE TO NEAREST; SEPTIC TANK = OTHER SEWER-LINES,.7 �:DISPOSAL FLO. FOUNDATION I AGRICULTURE WELL PROP. LINE OTHER WELL _� PITS/SUMPS INTENDED USE _ �- TYPE�LL PROBLEM AREA [:] Industrial -- CONSTRUCTION SPECIFICATIONS Domestic/Private f [f Open Bottom --�_]Manteca Dia, of Well Excavation f EJ Grave) PackTrac rpprox. Eastern❑ y Dia. of Well Casing ublic E]Othe � ❑ Irrigation A Type of Casing ! � �✓ Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal Other Type of Grout j Repair Work Done Surface Seal Installed by [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter •1 Sealing Material (top SD') Depth Filler 'Material (Below 50') V r i� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence ri available within 200 feet.) + Commercial Other r r Number of living units: Number of bedrooms [ Character of soil to a depth of 3 feet: Lot size SEPTIi TANK—`�_ Type/Mfg- i r Water table depth Capacity No. PKG. TREATMENT PLT. ❑ Type/Mfg 'F � - - —.,.. Compartments SEWAGE SYSTEM Capacity Method of'Dis"posal---� DESTRUCTION ❑ Distance to nearest: Well Foundation T� ~ Property Line �] LEACHING LINE [J— No. & Length of lines FILTER BED Total length/size Distance to.-nearest: Wellr Foundation •Property Line SEEPAGE PITS - ❑ Depth — Size Number SUMPS Li Distance t0"nearest: Well DISPOSAL PONDS Foundation Property Line F I hereby certify that I have preparedthisapplication and that the work will be done in accordance with San Joaquin county 1 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, 7 shall not employ any person in such manner as to become subject to workmans 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 sued, I shall employ persons subject to workman's compensation laws of California." The applicant st call f I re u'red ections. Complete dr Ing on revers 7-de. Signed° Title: EP RTM T USE ONLY Dater Application Accepted by r~J / Additional Comments: II Area Itk '466-6781 Pit or Grout Inspection by 0 Lodi - 369-3621 Final Inspection by Date ❑ Manteca 823-7104 Applicant - Return all copies to: Environmental Healt Permit/5ervicDese1601^J Eo Ave., Q,Tracy 200935Stk$5 CA 95201 . FEE BASE AMOUNT DUE INFO AMDUNT REMITTED RECEIVED BY RATE PERMIT N0. EH 13-24 REV. 16/82 14-26 10182 500