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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) . Appleication is hereby made.to the San Joaquin Local Health District for a permit to construct and/or install the workherein k 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 2p, '-7_5' Ive ig _e Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone R- TYPE OF WELL/PUMP WORK: NEW WELL Q 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 ' _n j INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca r, Dia. of Well Excavation Domestic/Private F_�Gravel Pack ❑Tracy Dia. of Well Casing Public Other i ❑ Delta Type of Casing — ' IrrigationA rox. Easterner ` ,w Lj 9 pp Speccations Cathodic Protection De th , . � pw �_: . .,� ��p ''�`":�c,` Depth of,;Grout Seal 17 6eaphysical�' Type of Grout +� . Other . - ` u Surface Seal Installed by - Repair Work'Done-�, Type of,.,Pump H.P: +� ;. State Wo k.Done Well Destruction U Well Diameter; X Sealing-Material (too 50') ( 1 'pepth' Filler Material (Below 50') w � , TYPE OF SEPTIC'WORK: NEW INSTALLATION U REPAIR/ADDITION U (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 size41 11 w H Ch46aracter of soil to a depth of 3 f et: Water table depth ka SEPTIC TANK 6 Type/Mfg Capacity Q' Na. Compartments *...44� ppKG, TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal Septl.c Tank r�ff - DeStruetion u Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines + Total ;en•th/size FILTER BED Distance to nearest: Well �K� Foundation Property Line — SEEPAGE PITS Depth Size Number SUMPS LJ A Distance to nearest: Well Foundation Property Line IISPOSAL PONDS FI�'--II t s 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. Home owner or licensed agent's signature certifies the following: "I certify that in the per.formance.of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman k 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 inspections. Complete drawing on reverse side. F Signed X Title: a Date: FOR DEPARTMENT USE-ONLY Application Accepted by Area Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Date ❑ Tracy 835-6385 x. Final Inspection by n P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY' i DATE PERMIT NO. INFO w F. EH 13-24 REV. 10/82 10/82 500 14-26