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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 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 p O described. This application is made in Compliance with San Joaquin County Ordinance No. 50.9 for sewage or No. 1862 for well/pump S� and the Rules and.Regulations the San Joaquin Loc 1 ealth District. Job Address Subdivision Name, Address Phone Owner's Name / ��f Contractor's Name License Nn_C�— � _ _ Phone TYPE OF WELL/PUMP WORK: NE4!W WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION /�� SYSTEM REPAIR OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK 1 *eq, SEWER LINES /j!9DISPOSAL FLD.' PROP. LINE FOUNDATION AGRICULTURE WELL r' OTHER WELL PITS/SUMPS ;'ooO o INTENDED USE TYPd OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind strial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation omestic/Private ravel Pack ❑ Tracy Dia. of Well Casing i Delta orl c ❑ Public ❑Other ❑ Type of Casing _—Ar o-9-501 ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal �S y ❑Geophysical Type of Grout (�e ❑Other `�/4 Surface Seal Installed by r \� Repair Work Done ❑ Type of Pump�� ``"� .PJ State Work Done Well Destruction F-1Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 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 feet_; Water table depth :i ; Capacity No. Compartments SEPTIC TANK ❑ ~Type/Mfg PKG. TREATMENT PLT. ❑ Type/MfgCpacity Method of Disposal IProperty Line SEWAGE SYSTEM f7 Distance to nearest: . Well Foundation DESTRUCTION LEACHING LINE ❑ No..& Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Sine 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 per of the work for which this permit i5 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'.certffy 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 mu all for al i ed inspections. Complete drawing on reverse side. / 7 Date: J Sig DEPARTME 3 ❑ Stk 466-6781 Applicata ccepted by' Area f ❑ Lodi 369-3621 t Additional Comments- // Manteca 823-7104 Pit or Grou Ins . ' n Date tea' 3 ❑ Date Tracy�', .? ❑ Tracy B35-6385 Final Inspection by Environmental Health Permit Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA Applicant - Return all copies t 95201 FEE BASE. AMOl1KTi .DUE- AMOUNT REMITTED . RECEIVED BY, DATE PERMIT N0. I INFO ] ��lb -+'azs �► I 10182 500 EH 13-24 REV. 10/82 ( 14-26