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APPLICATION FOR PERMIT r. OCTr� SAN JOAQUIN LOCAL HEALTH DISTRICT C ? 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 , DATE ISSUED+p SAN- JOAQUIN LOCAL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 00 HEALTH DISTRICT (Complete in Triplicate) Application is hereby-made to the San Joaquin Local Health District for a permit to construct and/or install the workiherein 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 ard.R ulations of the San Joaquin Local Health District. Job Address 1C96�-LL� t ame Owner's Name Address zv - Phone 9152--/ Contractor's Name �- ` License Na. +� Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR LL OTHER .+.aJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA .�_ CONSTRUCTION SPECIFICATIONS µ IJ Industrial U Open Bottom ❑ Manteca Dia, of Well Excavation " Domestic/Private F-]Gravel Pack Tracy Dia. of Well Casing Pub]ic �j Other Delta Type of Casing � V Irrigation �Approx. Eastern Cathodic- Protection `Depth Specifications Depth of Grout.Seal f EJ Geophysical Type of Grout U Other 6 Surface Seal Installed by Repair Work Done Q Type of Pump ,�.i�+ H.P. 3 State Work Done PA Well Destruction U Well Diameter T Sealing Material (top 50') ` Depth J Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is - 4 available within 200 feet.) ln,stallation will serve: Residence _ Commercial Other Number of living units: s Number of bedrooms' w r Lot size.— [. Character of soil to a depth of,'3�'feet::k Water table depth 1 SEPTIC TANK Type/Mfg -Capacity No. Compartments PKG, TREATMENT PLT. i Type/Mfg. } ++ "" { Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation, - Property 'Line DESTRUCTION ❑ a LEACHING LINE U No. S Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line -SEEPAGE P-I-TSDepth�_. Side = Number SUMPS l Distance to nearest: Well Foundation P Ll Line DISPOSAL PONDS CI 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 applicaq must ca r all required inspections. Complete dr ing on reverse side. Signed X k Title: -_'�.- _ Date: R ENT U NLY Application Accepted y Area �Stk 466-6781 Additional Comment + ❑ Lodi 369-3621 Pit or Grout Inspe on Date Manteca 823-7104 i Final Inspection by Date _�d— � , {� Tracy 835-6385 Applicant - Return all copies to:'. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 j [FEED BASL AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT N0. F 1-15 • ea C-3— - 10 'IRS. 10/82 500 EH 13-24 REV. 10/82 35fs1 14-26 a