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APPLICATION FOR PERMIT SAN JOAQU011 LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED � •3 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 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 rthe San Joaquin Lo 1 e I District. Job Address Q 1 rV t ubdivision Name Address Phone y Owner's Name Contractor's License No. . Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 1 M PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r �, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-11 PROBLEM AREA CONSTRUCTION SPECIFICATIONS'. �J I Industrial U Open Bottoff,, ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public [j Other �� Delta Type of Casing ' V Irrigation Approxi" ❑ Eastern Specifications Cathodic Protection Depth ? Depth of Grout Seal ❑Geophysicalf Type of Grout' U Other Surface Seal installed by Repair Wo k Done G Type of'Pump- H.P. State Work Done Sealing Material (top 50') Well Destruction U �Irl Diameter 9 , /Depth i Filler Material (Below 50') TYPE OF-SEP,TI&4WORK: NEW INSTALLATION REPAIR/ADDITION LJ -L septic tank or seepage P'availableewithid if nu20Dcfeet sewer is Instal--l.at on_will serve: Residence Commercial Other Number:of living units: Number of b rooms Lot size R Water table depth Character;of'soil to a depth qf.3 feet: [J Type/Mfg Capacity Q No. Compartments SEPTIC TANK PKG. TREATMENT PLT. Type/Mfg Capacity ` Method of Disposal SEWAGE SYSTEM Distance to nearest: Wel} C Q Foundation .�_ tProperty Line DESTRUCTION Total l r Y LEACHING LINE No. & Length of lines nth/size � � - Distance to nearest: Well O Foundation_ Property Line � FI LTERBEO;; .- r� Numb!.r ,SEEPAGE PITS Depth ��_ Size _a _ __ f Property Line SUMPS 4' � ��,f Distance to nearest: Well � ert Foundation /a- p Y DISPOSAL PONDS, �h 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 i's-i•ssued;' h shall not employ any`person 'in such manner as to become,subject to wcrkmars compensation laws of California." Contractor-'`s hjr' ing or sub-contracting signature certifies the following: ';I certify that in the performance of the work for which this permit.-1.I's issued, I shall employ persons subject to workman's compensation laws of California." The applicant' st call fo 11 equired inspections. Complete drawin n, verse side. 9 r r ` Date: Title: 1 Sighed X RwDEPARTMENT USE ONLY 5tk 466-6781 i Appl ' ti.o Accepted by _ Area ___ ( � Lodi 369-3621 I Addi ional Comments: anteca 829-7104 Ik Pit or Grout Inspection Date' Final Inspection by r •' '0'at ❑ Tracy 835-6385 Applicant - Return all copie to: . Envir nmenta Health Permit/Services 1 01 E Ha ton Ave., P.O. Box 2009, Stk., CA 95201 a FEEBASE AMOUNT CUE AMOUNT REMITTED RECEIVED BY �DPERMIT NO. DATE 3 ��yy INFOj��V - 10/82'500 ' EH 13-24 REV. 10/82 14-26 .. j