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APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED io PERMIT EXPIRES I 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 Re Mations of the San Joaquin Local He4 th.District. Job Address * Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone w t TYPE OF WELL/PUMP WORK: j�' NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTId TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ~ INTENDED USE '� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation LJ Domestic/Private ri Gravel Pack [:]Tracy Dia. of Well Casing 0 Public F1 Other 0 Del to Type of Casing L_IIrrigation II Approx. ❑ Eastern M Cathodic Protection !" Depth Specifications Depth of Grout Seal i 1-1 Geophysical Type of Grout FJ Other i Surface Seal Installed by ' Repair Work Done ❑ Type of Pump H.P. State .Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') �/— TYPE OF SEPTIC WORK: NEW INSTALLATION [; REPAIR/ADDITION� (No septic tank or seepage pit permitted if public sewer is 1' available within 200 feet.) Installation will serve: I�iResidenceA/ Commercial Other , Number of living units: =4 Of Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK L Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Di�ppsal SEWAGE SYSTEM Distance to nearest: Well , Foundation _ V_ Property Line DESTRUCTION 11 fow LEACHING LINE ❑ No. & Length of lines Total length/size 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 I 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 shallnot employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or subcontracting 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 applic all or all a uired inspections. Complete drawing an reverse side. Signed X Title: _ /dL��/�]/(� � Date: �( / iF �NTUSEY Application Accepted i by Area d Z ❑ Stk 466-67 1 n Additional Comments: Lodi 369-3621 Pit or Grout Inspection bye, Date G �Z(} 0 Manteca 823-7100. i Final Inspection byi — Date .�1ZC5_-E4) Lj Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r !i 4 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DA�TE PERMIT NO. � INFO C//O 1/V �J_S4/O() iI EH 13-24 REV. 10/82 ! 10/82 5Do 14-26 J ,