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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE I55UED , PERMIT EXPIRES 1 YEAR FROM DATE I55UED (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. 1852 for well/pump and the Rules and Regulations of the,San Joaquin Local Health District. Job Address It — Subdivision Name Owner's Name Address Phone Contractor's Name License No. � � Phone TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ O� PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ O.) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS # INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y El Industrial U Open Bottom Manteca Dia. of Well Excavation U Domestic/Private ❑Gravel Pack Tracy Dia: of Well Casing Public CJ Other Delta Type of Casing Irrigation Approx. Eastern Depth Specifications Dep Cathodic Protection - Depth of Grout Seal Geophysical Type of Grout [J Other Surface Seal Installed by Repair Work Done [ Type of Pump H.P. State Work Done Well Destruction [I Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') a I TYPE OF SEPTIC WORK: NEW INSTALLATION E .REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residencet_/ Commercial,. Other .. �. Number of living units: _/_ Number of bedrooms — Lot size �y •t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK E&- Type/MfgCapacity. j No. Compartments h 2.. .� PKG. TREATMENT PLT. ❑ Type/Mfg # Capacity Method of Disposal' J. SEWAGE SYSTEM, W Q Distance to nearest: Well W07� Foundation U Property Line ESTRUCTI — v - LEACHING LINE No. & Length of lines Total length/size ' 13 U FILTER BED Distance to nearest: Well I Foundation tf 4 Property Line SEEPAGE PITS [ Depth s Size W _ Number SUMPS �} Distance to nearest: We1T �_- Foundation___ Property Line 7Q t »- DISPOSAL PONDS [� > r , 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 j permit is issued, I shall not employ any personain such manner as to become subject to workmant compensation laws of California." 3 Contractor's hiring or sub-contra ting signature certifies'the'fallowin'g':- "I certify that in the performance of the work for which a this permit is issued, I sh 1 em Toy persons subject to workman's compensation laws of California/" The applicant cal equired inspections. Complete drawing on reverse side. Signed X Title:i Date: FOR DEPARTMENT USE-ONLY i Area Stk Application Accepted by � k466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspectio Date U Manteca 823-7104 j Final Inspection by A6Date Tracy 835-6385 Applicant - Return all copiffs to: En ironmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FE£ BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYa. - DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26