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APPLICATIOiN FOR PERMT SAN JOAQLiN LOCAL HEALTH _,STRICT i 1601 E. IAZELTCN AVE., STUCKTON, CA PERMIT NO. Telephone (209) 466-6781 `� 1 T y�6 PERMIT EXPIRES 1 YEAR-FROM DATE ISSUEO DATE ISSUED p (Complete in Triplicate) # I 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 Regulations of he San Joaquin Local Health District, Job Address/ Z s(f//?� subdivision Name Owner's Name ,f _ _Address Phone Contractor's Name License No. Phone $ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 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.17 } Industrial ❑ Open Bottom Man ca Dia. of Well Excavation jJ Domestic/Private ❑Gravel Pack Tr cy Dia, of Well Casing ❑ Pub]ic ❑ Other elta u Irrigation Approx. E rn Type of Casing Depth Specifications Cathodic Protection p Depth of Grout Seal ❑Geophysical Other Type of Grout 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump 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 X (No septic tank or seepage pit permitted if public sewer is 6 Installation will serve; available within 200 feet.)Residence _ Commercial � Other }`�t 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 Al Capacity No. Compartments i PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal . SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ i LEACHING LINE a No., & Length of lines Total length/size t FILTER BED ❑ Distance—to-nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ � ,� J, 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, C 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 workman5 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 i this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Area Stk 466-6783 Additional Comments: / m'lS X.& / Z [] ,Lodi 369-3621 f Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date 7 ❑ Tracy 835-6385 Applicant - Return all copies to: . Lnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 i