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APPLICATION FOR PERMIT t SAN JOAQUIN' LOCAL HEALTH-DISTRICT �3 3a f 1601 E. HAZLLTON AVE., STOCKTON, CA PERMIT N0. I Telephone (209) 466-5781 C PATE ISSUED c] r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . k-7! h S �� • (Complete in Triplicate) �� 1 _ �-7 p 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 the�San•Joaquin Local Health.District. Job Addresst"1 E d Subdivision Name Owner's Name ,h Address _ Phone. t s Contractor's Name License,No. 7 Phone E TYPE OF WELL/PUMP WORK: NEW WELL- ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ V" DISTANCE TO NEAREST: SEPTIC TANKI SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V� ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I- - --_ T _ �•_ v_.— r� K- max �� of-::Wel-I Exca.vation I� lndusYrial - U'Op�n Bottom []Manteca`- ❑ Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing P lic Other Delta ❑ ❑ ❑ Type of Casing Irrigation Approx. Eastern Specifications Cathodic Protection Depth � [] Depth of Grout Seal 1 ❑Geophysical Type of Grout �J ❑Other Surface 'Seal Installed by Repair Work Done t/ITYPI of Pump H.P. State Work Done 3—cLe. IS ;,sllf� GA`L- - � Well Destruction F-1WellDiameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIDN ❑ REPAIR/AODITIDN ❑ (No septic tank or seepage pit permitted if public sewer is availabie within 200 feet.) Installation will serve: Residence — Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK �j Type/Mfg Capacity No. Compartments' PKG. TREATMENT PLT. [—I Type/Mfg Capacity Method of Disposal Property SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation P y Line — OESTRUCTION LEACHING LINE ❑ No. &Length of lines Total length/size r Property Line FILTER BED ❑ Distance to nearest:_ Well Foundation P I , SEEPAGE PITS ❑ Depth` Size Number SUMPS I—I Distance to nearest: Well Foundation Property Line x DISPOSAL PONDS ❑ " i 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 sha17 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 ornia.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. Date: S Signed A_ �•- Title: FO RE RTMENT USE ONLY rea _ �; Stk 466-6781 Application Accepted by ' � Lodi 369-3621 Additional Comments: 'Pit or Grout Inspection h Date ❑ Manteca 823-7104 f{r Date Tracy 835-6385 Final Inspection by- Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 5 3 3 10/82 500 EH 13-24 REV. 10/82 14-26 h 4