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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 (Conplete 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 She San Joaquin Local Health District. Job Address S, '� l Subdivision eName Q F, Owner's Name v U 1 Y Address f U ! J� �---� Phone Contractor's Name 1 License No. Phone W I 1 E TYPE OF WELL/PUMP WORK: NE4f#WELL 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 INTENDED USE TY71E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open}Bottom F Manteca Dia. of Well Excavation LJ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing Public Other Delta Type of Casing V Irrigation Approx. Eastern Specifications Cathodic Protection Depth Depth of Grout Seal Geophysical ` Type of Grout Other Surface Seal Installed by Repair Work_ Done ❑ Type of Pump H.P, State Work Done J { Well Destruction U Well Diameter{ Sealing Material (top 50') $ Depth Filler Material (Below 50') 1 `il TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION [_J (No septic tank or seepage pit permitted if public sewer is 11 available within 200 feet.) Installation will serve: Residence — Commercial _ Other m Number of living units: Number of bedrooms Lot size Water table depth Character of soil to a depth oT feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION I LEACHING LINE ❑ No. & Length of lines Total length/size. 1 r Property Line FILTER BED � Distance to nearest: Well Foundation y SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS CI h 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. ork for which this Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the w permit is issued, I shall not employ any person in such manner as to become subject to worknan� 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 f�all for all re uir �inspect�lons. Complete drawing on reverse side. _ Signed l ! �+ ! Title: L-s!v`r� Date: i/'1 FOR PRNT USE ONLY 0 Stk 466-6781 Application Accepted by •��J Area Lodi 369-3621 Additional Comments: I Pit or Grout Inspection by Date S Gr/l I� Manteca 823-7104 Date Tracy 835-6385 Final Inspection by ti. 2 Applicant - Return all copies to i Environmental Health Permit/Services 1601 E. Hazelton Live., P.O. Box 2009, St k., CA 95201 r1N BASE AMOUNT'IDUE AMOUNT REMITTED RECEIVED BY DATE �.y PERMrIT` N0. O I.�o l o an. 'v 10/8Z 500 C EH 13-24 REV. 10/82 14-26