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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED 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 Reggulatio of the S n Joa�q�in Local Health District. ��yJ� Job Address n+� Sy�j�cisian-MaMI� �f_myob Owner's Name Ci Address Phone _W%1` J3` ,3 Contractor's Name le-4* t i c e n s e No. lo; 2� '. Phone �CS' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER f_1 (� 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 oLj Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing ❑ Public ❑ Other ❑Delta Type of Casing Irrigation Approx. ❑ Eastern Depth Specifications F-1CathodicProtection 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 ❑ Well Diameter Sealing Material (top 50') ob Depth Filler Material (Below 50') a TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,4DDITION (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _I/ Commercial _ Other Number of living units: Number of b drooms - Lot size rlla ' Character of soil to a depth of 3 feet: Water table depth 1 C e SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM 11---� Distance to nearest: Well Foundation Property Line DESTRUCTION U LEACHING LINE No. & Length of lines J ! Total length/size , FILTER BED ❑ Distance to nearest: Well ! Foundation �/ / Property Line SEEPAGE PITS Depth �jr� Size �� Number L_ SUMPS ❑ Distance to nearest: Well D C Foundation _�(i Property Line 7 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 workmanIs 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 issued, I shall employ persons subject to workman's compensation laws of California." The applica t m t call for all requ' ed nspections. Complete dra ing on reverse side. / p Signed X Title: )�N�C' Date: 7S FOR DEPARTMENT USE ONLY /11 ❑ App ication Accepted by Area V�1 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by DateManteca 823-7104 Final Inspection by Date L7Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Lt 91 13 g3- EH 13-24 REV. 10/82 10/82 500 14-26