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• APPLICATION FOR PERMIT SAN JOAQU-N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 'g3�3 Telephone (209) 466-6781 PERMIT NO. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 1 described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well and th ur .s Re la 'ons f\the San oaquin Local Health District. + Jab Adat Subdivision Name Owner's Name Address .t 1 I Contractor's ame a Phone ' License No. Phone TYPE OF WELL/PUMP WORK: NEW WELLHELL REPLACEMENT G ❑ DESTRUCTION❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP.A INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial �— ❑Open Bottom ❑Manteca Dia, of Well Excavation ❑Domestic/Private ❑Gravel Pack Trac I]Public y Dia. of Well Casing ❑OtherDelta F i ❑ Irrigation ❑ Type of Casing Approx. ❑Eastern ❑Cathodic Protection Depth Specifications �f ❑Geophysical Depth of Grout Seal F 1 ❑Other Type of Grout Repair Work Done [] type of Pump H,p Surface Seal Installed b y FI State�Work Oone Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 5o') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION U Io'septic tank or seepage pit permitted if pubic sewer is r Installation will serve: Residence ` Commercial _ Other available within 200 feet.) Number of living units: Z_ Number of bedrooms ';P— Lot Lot si a�OX.C. , Character of soil to a depth of 3 feet: i CCI��,[9 441.— Water table depth / SEPTIC TANK Type/Mf g =1�4�iL.i�1 Capacity ''�f�- No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation t Property Line / DESTRUCTION D � ` LEACHING LINE No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS (/ Depth ! Size Number f F1. SUMPS U Distance to nearest: Well 1c�� Foundation ` !!S: Property Line 1111 DISPOSAL PONDS ❑ `~ � p y *16 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 issued, I ail ploy persons subject to workman's compensation laws of California.' The applicant call required inspections. Complete drawing on reverse side. Signed X Title: 466& Date: FOR DEPARTMENT USE ONLY~ Application Accepted by Area 0 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout inspection Date ❑ nteca 823-7104 Final Inspection by Date Tracy 835-6385 --: Applicant - Return all capie to: Environmental Health Permit/Services 1601 E. Vel6t.n Ave., P.Q. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AHNNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EIi.13-24. REV. 10/82 500 / I y