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L vim APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT yiC$al `t 1601 E. HAZELTON AVE., STOCKTON, CA f PERMIT N0. �J _ Telephone (209) 466-6781 � SAN .��p�y�g� ,®CAL. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 3 g STRICT (Complete in Triplicate) F 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 AddrEssaa iceSubdivisionAddress ' Name Owner's Name Address [� Phone Contractor's Name License No, Phone TYPE OF WELL/PUMP WORK: NEW}WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Bottom Manteca Openi E ❑ Dia. of Well Excavation Domestic/Private E]Gravel Pack ❑ Tracy ,'Dia. of Well Casing `� Y ❑ Public ❑ Other ❑ Delta V irrigation Type of Casing g Approx. Eastern Specifications ❑ Cathodic Protection Depth S P Q, ❑Geophysical Depth of Grout Seal ifit r Other Type of Grout S Surface Seal Installed by Repair Work Done I Type of Pump i H.P. State Wor�Do �� Well Destruction Lf Well Diameter Sealing Material (top 50')_ Z Depth F Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U p seepage p permitted if public sewer is U (No septic tank or see a e it ; Installation will serve: Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Lot size Character of soil to a depth of ;.feet: Water table depth Cl` 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 ❑ i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ._ ED s 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 applica, 'musth c�foral requirs.ed inspections. Complete dr g n reverse side. Signed XTitle: Date: _,EOR EPARTMENT US NLY Application Accepted by �y Area F Stk 466-6781 Additional Comments: 1 Lodi 369-3621 Pit or Grout Inspection by DatePW �1Nanteca 823-7104 Final Inspection by Date — ��`I lL�Tracy 835-6385 Applicant - Return all copies to: . En vironme tal 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 J� Eh 13-24 REV. 10/82 C_�3 q$ 20/82 500 14-26