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r APPLICATION FOR PERMIT SAN JOAQU11 LOCAL'HEiiLiH DISTRICT 9 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 R_ DATE ISSUED PERMIT EXPIRES 1 YEAR/FROM DATE ISSUED (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 Reg i t' of the ,S auin Lac ealth District, —} Job Address ' ole Subdivision Name Owner's••Name l - Address Phone Contractor's Name License,No• Phone (� w I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ `� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1❑ Industrial ❑ Open Bottom ❑ Manteca ` r. 4 Dia. of Well Excavation F—JDomestic/Private ❑ Gravel, Pack ❑ Tracy Dia. of Well Casing' W,_ - "�❑ Public "�"" �"' ❑ Others rr❑ Delta Type of Casing V Irrigation Approx. ❑ Eastern Specifications tI 11 Cathodic Protection Depth Depth.of Grout Seal ❑Geophysical i Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work 'Done z_ Well Destruction ❑ Well Diameter Sealing Material (top 50') epth_ _.._� __.- Fa1er_Material (Below 50') TY_P_E-OF -SEPTIC:WORK:=-NEW INSTALLATION-�, -REPAIR/ADDITION-❑'`(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 fee - Water table depth s� SEPTIC TANK ❑ Type/Mfg ��Cei-t'y _� d0 No. Compartments PKG. TREATMENT P-LT. ❑ Type/Mfg K Capacity Z. Method of Disposal Distance-to nearest: Well. Founda&n � _ Line SEWAGE SYSTEM __. `� " Property_Line _. .-- -..• DFSTRUCTION I- . ' I LEACHING LINE No. & Length`.of lTotal 1ines. x., �� ergth/—sfie, FILTER BED ❑ Distance ea est Well 1 p� Foundation 'Property Line SEEPAGE PITS ❑ Depth ? Size, Number_ SUMPS Distance-to:nearest`: Wel l Foundation yProperty Line DISPOSAL PONDS ❑I '� f 1 ^ I hereby certify that L;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 thisJ� permit is issued, I shall ,not employ any person in such'manner as to become subject tthat"cman s compensation laws of California."i Contractor's hiring or sub-contracting signature certifies"the following: "I certify that"in the performance of the work for which this permi,t°is:',issued, I shall employ persons subject to workman's compensation laws of California." Thea licant mu -car•1 for 11 quired inspections. .Complete drawing on reverse 51de Pp \ ! ,. . _w:-� .-- A f / Dater s Signed X G.(. Title: CX•lf'�''f/ FOR DEPARTMENT USE ONLY Application Accepted.by Area Stk r 466-6781 Additional Comments: ❑ 'Lodi-. 369-3621 Pit or Grout Inspection by Date= ❑ Mante8a'823-7104 Final Inspection by /gull" Date �� ❑ Tracy 835=6385 4 v-. Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E, Hazelton Ave., P.O. Bax 2009, StkR 95201 FEE BRS£ MOUNT DUE AMOUNT REMITTED RFCEIVED BY DATE PERMIT N0. /- INFO i c7 S— ., 10/82 500 EH 13-24 REV. 10/82 �. 14-26 .! x v 1