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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. T��-� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED L44 v (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 is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulatio s of the San Joaquin Local He 7t District. Job Address r u division Name Owner's Name 1 Address Phone Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT ❑ ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open BottomManteca ❑ Dia. of Well Excavation ❑ Domestic/Private (�Gravel PackTrac ❑ Y Dia. of Well Casing ❑ Public L_jOther ❑ Delta U Irrigation Type of Casing Approx. ❑ Eastern []Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal s ❑Other Type of Grout 1 Surface Seal Installed by Repair Work Done EJ_ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION No septic tank seepage pit permitted if public sewer is Installation will serve: Residence Commercial _ Othe bC) or, available within 200 feet.) Number of living units: --t-_ Number of bedrooms ` Lot size AC Character of soil to a depth of 3 feet:_ � Water table depth ' SEPTIC TANK A� Type/Mfg r —�--- Y Capacit - No. Compartments ^--�- PKG. TREATMENT PLT. ❑ Type/Mfg Capacity-. Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑j Depth Size Number SUMPS ❑# 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 issue I shal9 not employ any p on in such manner as to become subject to workman compensation laws of California." Contractor's h' ing or sub-contracting si ature certifies t following: "I certify that in the performance of the work for which this permit ssued, I shall employ pe ons subject to wor ian's c pensation laws of California." The appli cal] far l re ui insp coons. Comple ra on reverse side. Signed Title; _ Date: FOR�RTME T USE 0 Y, Application Accepted by Area r/ Stk 466-6781 Additional Comments: , � . /may � ❑ Lodi 369-3621 Pit'or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date/L 16 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 16(i E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 4 1a io ��--7I 7 EH 13-24 REV. 10/82 14-26 10/82 500 .