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APPLICATION FOR PERMITQQA �� SAN JOAQUiN LOCAL HEALTH D1STR �� ) �5 � 1601 E. HAZELTON AVE., STOCKTON, ` �r x (%4fRMIT NO. Telephone (209) 466-6781 � � PATE ISSUED 5�1� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED [�N,,-�(��yy 4 (Complete in Triplicate) S 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. 544, for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jab AddressQta Subdivision Name Owner's Name Address Phone 17--32Z Contractor's Name 4: License No. 1 - Phone �- TYPE OF WELL/PUMP WORK: NEVI WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR L{ OTHER ❑ 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 Industrial yU Open_ Bottom Manteca Dia. of Well Excavation Domestic/Private Gravel Pack F-1 Tracy Dia. of Well Casing ❑ Public [j Other Del to irrigation Approx. Eastern Type of Casing ❑ ❑Cathodic Protection Depth Specifications Depth of Grout Seal Geophysical ❑Other Type of Grout Surface Seal Inst led by Repair Work Done Type of Pump tP, H.P, State Work Done Well Destruction Well Diameter Sealing Material (top 501) Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 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 3,feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No.. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line a SEEPAGE PITS ❑ Depth Size Number i SUMPS Distance to nearest: Well Foundation -'Pro-o-p'erty Line DISPOSAL PONDS C� M 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 performanc`e 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 applicant i st al�fl�] pections. Complete dr g on reverse side. Signed X Title: d,. Date: R DEPARTMEN SE ONLY .�/U� Application Accepted by Area [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspectiok by Date anteca 823-7104 Final Inspection by Date Tracy 835-6385 k Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave, P.0. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CC � EH 13-24 REV. 10/82 10/82 500 14-26 � ��k7