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a tA 2 APPLICATION FOR PERMIT a �� SAN JDAQUiN LOCAL HEALTH DISTRICT I 1601 E. HAZELTON AVE., STOCKTON, CA ' PERMIT NO. Telephone (209} 466-6781 DATE ISSUED 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 4 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 Lca Health District. { Job Address Q J p Subdivision Name Owner's Name Ma y Man Address 9 J?V/ Phone 3— Contractor's Name eLicense No, IR Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK ``G SEWER LINES DISPOSAL FLD. J� PROP. LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (` ❑ Industrialj_Open Bottom Manteca Dia, of Well Excavation Domestic/Private ,Gravel Pack ❑ Tracy Dia. of Well Casin�g/ f ❑ Public CJ Other ❑ Delta Type of Casing {� �� f F, g Irrigation A f Depth Eastern Eastern Specifications ❑ Cathodic Protection p Depth of Grout Seal (f ❑Geophysical frType of Grout her y� r 00 At I Surface Seal Installed by 7Type Repair Work Done of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') U TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial _ Other n Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size 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 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, I 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 e Toy persons subject to workman's compensation laws of California." The applica us call or 1 equired inspections. Complete drawi�q�verse side. Signed X Title: Date: 6& ��®®�� F D RTMENT USE ONLYg�^ Rpplti Acced y Area [] Stk 466-6781 Lodi 369-3621 Additional Comments: / ❑ s Pit or Grout Inspection by Date — =- Manteca 823-7104 d< ',- Final Inspection by Date fp` 9 � ❑ racy 835-6385 Applicant - Return all copies to: Environmental Health P mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA .95201 • x� FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �PERMITNO.INFO / SS � 10/82 500 FH 13-24 REV. 10/82 14-26