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. k APPLICATION FOR PERMIT SAN JOAQUIN' LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 Telephone (209) 466-6781 DATE iSSUEO 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 Regulations of the San Joaquin Local Health District. Job Address Subdivision Name W _ /- Owner's Name �Y Address 10V Phone Contractor's Name r icense No. Phone TYPE OF WELL/PUMP WORK: NEL! WELL WELL REPLACEMENT DESTRUCTION Q- PUMP INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK /QQ� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL "OTHER WELL PITS/SUMPS /tee "IF INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 J Industrial (J Open Bottom F] Manteca Dia, of Well Excavation Domestic/Private [Gravel Pack F1 Tracy Dia, of Well Casing Public F—i Other ❑ Delta Type.of Casing V Irrigation Approx. Eastern Specifications r—ICathodic Protection Depth Depth of Grout,Seal ❑Geophysical ` Type of Grout U Other Surface Seal Installed by Repair Work Done EJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (BBlow.50'r)- TYPE D)_TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 1 available within 200 feet.) 1 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 U Type/Mfg Capacity No. Compartments f s PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal j SEWAGE SYSTEM c Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size I FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ ' d 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 ]oaquin 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 shalt 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 issued, I shall employ persons subject to workman's compensation laws of California." The applicant.m ll for all required inspections. Complete drawing on a erse side. Signed X Title: ate: FOR DEPA S Y ❑ Application Accepted b Area Stk 466-6781 Additional Commen ' Lodi 369-3621 Pit or Grout Ins ion by Date *J �azelt.n !� LJ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1Ave., P.O. Box 2009, Stk., CA 95201 FFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. jai 3-`1 (� . EH 13-24 REV. 10/82 10/82 500 14-26 i ,.