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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT /1 7 3 1601 E. HAZELTON AVE., `1 STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED s (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 1s 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 Address 9— Y-7 Subdivision Name Owner's Name �` Phone Address & Contractor's Name License No. 059 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ ESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS {)J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1❑ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation F_lDomes0c/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth m Depth of Grout,Seal ❑Geophysical Type of Grout ❑Other I/� Surface Seal Installed by Repair Work Done Type of PumpI N.P. `/ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') d TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [D (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: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 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 LEACHING LINE ❑ No. & Length of lines e 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' 0 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 ag sig ture certifies the following: "I certify that'in the performance of the work for which this permit is iss d, I sha not empl y any person in such manner as to become subject to workman compensation laws of California." Contractor's ring ors -cont a i si ature rtifies the following: "I certify that in the performance of the work for whi this perm'Wuw issu all 1 pe ns sub ect to workman's compensation laws of California." The appli 1 fo 1 eq 'red e t' s. Complete drri�gP reverse side. �� Date: Signed X Title: d F DEP TMENT U E ONLY ❑ Stk 466-5781 Application Accepted Area ❑ Lodi 369-3621 Additional Comments: Pit or Grout Inspection by Date' ❑ Manteca 823-7104 I Final Inspection by Date /3— � ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health/Permit/Services 1601 E. Hazelton Ave., P.O.. Box 2009, Stk., CA 95201 FEEBAS£ AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NU. INFO a� 3 3-�3 10/82 500 FH 13-24 REV. 10/82 14-26