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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA NO. Telephone (209) 466-6781 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 t e 5 n Joa uin Local Health District. Job Address 6Ll� Subdivision Name Owner's Name Address 3 Phone 1!� 3/ ISA Contractor's Name License No. Phone Phone Ct�1� 'ril TYPE OF WELLL4 M� WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION / I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Afft4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA industrial U Open Bottom Manteca Domestic/Private Gravel Pack [f Tracy CONSTRUCTION SPECIFICATIONS Dia, of Well Excavation Dia. of Well Casing 17 Public F Other Delta Type of Casing Irrigation Approx. ® Eastern Specifications Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done N► Type of Pump rk!!� H.P• / State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: .NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit pirmittedlable ifputhin blicfsew ) is ava Installation will serve: Residence _ Commercial — Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: SEPTIC TANK Cj Type/Mfg PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM Distance to nearest: Well DESTRUCTION Water table depth _ Capacity No. Compartments _ _ Capacity Method of Disposal Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS F1 Distance to nearest: Well Foundation 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. 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, 1 shall 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 must c 1 for all required inspections. Complete drawing on reverse side. e 'w Signed X ,( Title: Date: FOR DEPA ENT USE ONLY �Stk 466-6781 Ap . ication Accepted by 4 Area Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copie Enviro mental me Permit/Services 16D1 *,el�ton Ave., P.O. Box 2009, St k., CA 95201 FEE I BASE I AMOUNT DUE INFO AMOUNT REMITTED I RECEIVED BY DATE I PERMIT NO. U 10182 500 EH 13-24 REV. 10/82 14-26 LA to