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APPLICATION FOR PERMIT ' SPM JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED p=� 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 Regulation//s of the San Joaquin Local Health District. Job Address 9�� fh.itIf Subdivision Name Owner's Name Address Phone V- YM Contractor's Name License No. Phone , TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP: LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j/ INTENDED USE TYPE OF WELLf 3 PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ Industrial U Open Bottom. F� Manteca Dia. of Well Excavation U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public ! Other Del to �] Cl 1 0 Type of Casing [j irrigation Approx. Eastern Specifications F-1Cathodic Protection zptri Depth of Grout Seal Geophysical Type of Grout Other �� s.. Surface Seal Installed by Repair Work Done Q Type of Pump H.P. I State Work Bone Well Destruction U Well Diameter Sealing Material (top 50'..) Depth ALi Filler Material (Below 50') TYPE OF SEPTIC,WORK: NEW INSTALLATION FZX REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation"wi•11=serve:_j.Residence. Commercial' l' Other r of bedrooms~ 4,` Number of;livi g units: = _�Numbe ^ .� Lot size Character'oflsoil to a depth ,of 3 feet:l Water table depth SEPTIC TANK _ '"Type/Mfg ��J�,.� Capacity �,2Q[� No. Compartments yy, PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal r SEWAGE SYSTEM t Qistance-to.nearestt: .Well � = Foundation Property Line DESTRUCTION LEACHING LINEA, U /No.-,-& Length of lines' fw Total length/size (� l " 1®+ Property Line r FILTER BED A� ,Distance to nearest: -" ell- y Foundation p s ' SEEPAGE PITS ❑ Oepth ; Size 3$ Number SUMPS �� Distance to nearest: Well ' Foundation'',.: Property 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-regulationstof 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:emQloy,any person in such manner as to become subject "to workmanis compensation laws of California." Contractor's hiring or sub-contracting signature certifies the'following:' 11I-certify"that ire-'the performance of,the work for which thik permit is issued, I shall employ persons subject to workman's compensation laws of California." n Complete drawing on reverse side. The applicant must call for all required inspections, Q 9 � Signed X Title:' - Date: - FOR DEPARTMENT USE ONLY iL Stk 466-6781 Rpplication Accepted by � . Area _�__,�_ Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date El Manteca 823-7104 Final Inspection by A" Date ❑ Tracy 835-6385 Applicant - Return all copies to: EnvironmentalVHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �� 5 �� o•- ��'S'd s 10/82 500 EH 13-24 REV. 10/82 Q�� 14-26 l•