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APPLICATION FOR PERMIT I SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED1—17—&3 ' 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 andegulati ns o the San qu' Local, Health District. , Job Address i IiC>� Subdivision Name 9LN Owner's Name Address Phone Contractor's Name License No. Phone&X& 7:h:11r� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER LJ W 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 Industrial U Open Bottom Manteca Dia. of Well Excavation ❑ Domestic/Private Gravel Pack Tracy Dia. of Well -Casing 1] Public Other Delta Type of Casing Lj Irrigation Approx. Eastern Specifications Depth❑ Cathodic Protection Depth of Grout Seal ❑Geophysical Type of Grout [] Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction .0 Well Diameter Sealing Material (top 50') ' ' FillerMaterial (Below 50 ) Depth -- TYPE OF SEPTIC WORK: NEW INSTALLATION.LI REPAIR/ADDITION ] (No septic tank or seepage pit permitted-if public sewer is d available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: Number of drooms —3— Lot size Character of soil to a depth of 3 fee r1 Water table depth SEPTIC TANK Type/Mfg Capacity� -- No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION C1 LEACHING LINE ] No. & Length of lines '"' Total length/size FILTER BED Distance to nearest: Well C)0-0 d�•'i Foundation f� Property Line i '�- SEEPAGE PITS Depth Size 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 performance of the work for which this permit is 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 certify that in the performance of the work for which this permit is ed, I shall ploy rsons subject to workman's compensation laws of California." The appli nt mu call for 11 eq ections. Complete drawing on reverse side. 3 A.-, Title: Date: Signed ��yy�� OR ARTMEN USE ONLY Q Stk 466-6781 ��C. Application Accepted by Area Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final inspection by Date f9 /8I JO ❑ Tracy 835-6385 fApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 3 ff-13 F-93-IS-9 1D/az 500 EH 13-24 REV. 10/82 14-26