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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40. Telephone (209) 466-6781 DATE ISSUED �f 15-�3 3 PERMIT EXPIRES I 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 Aek"o 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 LoCAkHealth District. r' �C /� Job Address Subdivision Namei�0 ( 1a2z6/1 A Jr f,�'1� _ �! Owner's Name Or Address Phone Contractor's Name icense No. Phone I dr r jr TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U QQ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r,} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —' Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation �\ U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing L7 Public F—IOther Delta Type of Casing "I V Irrigation Approx. Eastern Depth Specifications 71 Cathodic Protection ' Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done FJ Type of Pump H.P. State Work Done Al Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') . TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (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: Numb of bedrooms Lot size Character of soil epi of 3 feet: Water table depth SEPTIC TANK Type/Mfg pacity F I No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal \ ^ SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE4A Cop No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation + Property Line I ' SEEPAGE PITS Depth _ Size 'S Number SUMPS U 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 employ persons subject to workman's compensation laws of California." The applicant must call for all q 'red inspect ns Complete drawing on reverse side. Signed X9,3 Title: Date: [� FO P I ONLY ,IL•�3 Application Accepted by Area Stk 46fi-67 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date a Manteca 823-7104 Final inspection by Date �� /� ❑ Tracy 835-6385 Applicant - Return all copies o: Environmental alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT pUE AMOUNT REMITTED RECEIVED BY DATE PERMPNO. INFO ;13- j 5� EH 13-24 REV. 1D/82 10/82 50C 14-26