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i APPLICATION FOR PERMIT y SAN JOAQUiN LOCAL HFALTH DISTRICT ��J 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. r Telephone (209)•466-6781, `7 2 DATE ISSUED d J PERMIT EXPSRES 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 I and.the Rules and Regulations of the San �Joaquin Local Health District, Job Address �jf�iM � ]J-��iLlJi6`/�77(� Subdivis_ion Name —" Owner's Name _ Address Phones Contractor's Name t License No. R Jk S#'!:? Phone TYPE OF WELL/PUMP WORK: NNIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (N 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 Industrial ❑ OpenlBottom ❑ Manteca Dia. of Well Excavation lJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing v ❑ Public �j Dthe� ❑ Delta Type of Casing Irrigation 'Approx. ❑ Eastern Specifications E ❑ Cathodic Protection Depth roDepth of Grout Seal ❑Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter# Sealing Material (top 50') Depth 1 Filler Material (Below 50') -_ 3 t1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION {No septic tank or seepage pit permitted if public sewer is I 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg E Capacity No. Compartments� PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal i SEWAGE SYSTEM o Distance to nearest:,,"Well Foundation Property Line P DESTRUCTION LEACHING LINE No. & Length ofelines. ♦d Total length/size FILTER BED ❑ Distance-to nearest: Wel] Foundation IAf! Property Line SEEPAGE PITS ❑ Depth Size Number t SUMPS Lu: D. 'stance 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 issued, I shall not employ any person in such manner as to become subject to workman s compensation laws of California." Contractor's hiri or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which this permit is ed, I shall employ persons bject to workman's compensation laws of California." f The applica �us, all for requ' i tion Complete a ng o verse side. r Signed itle: Date: 1 "' OR'DEPARTMENT USE ONLY Application Accepted by Area 1-- ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 ` Pit or Grout Inspection byT Date Manteca 823-7104 Final Inspection by1 Date �� L} Tracy 835-6385 Applicant - Retu`rn all copie :# Environmental Health Permit/Services 1601 E. Hazeltdn 1 ., P.O. Box 2009, St k., CR 95201: FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO J EH 13-24 REV. 10/82 1OJ82 500 14-26 t {