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`w APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 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 Regulations of the San Joaquin L cal Hea District. Jab Address ife LIQ ubdivision Name �n/�� Owner's Name "O Address Phone Contractor's Name wlw ense No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ribG5 PUMP INSTALLATION SYSTEM REPAIR/ OTHER ❑ (' S- DISTANCE ' L DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES —! �- DISPOSAL FLO. PROP. LINE L i FOUNDATION �� - AGRICULTURE WELL OTHER WELL >W�PITS/SUMPS ISD T UJ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOtS 1-1Industrial ❑Open Bottom F-1Manteca Dia. of Well Excavation ZVeA (p,fGmestic/Private ravel Pack ❑Tracy Dia. of Well Casing 450 .GGF 0 Public ❑ Other ❑Delta Type of Casing 4(ea ®Z G Lj Irrigation Approx. ❑Eastern Specifications/ ❑Cathodic Protection Depth Depth of Grout Seal �'- ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done ❑ Type of PumpcH.P. `�_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other _ Number of living units: Number of bedrooms Lot size Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ION ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS IJ 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 workman4 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 applican call for all required inspections. Complete drawing on reverse side. 7� Signed X Title: � �� Date✓' D ARTMENT USE ELY „ 3 ❑ Stk 466-6781 Application Accept by Area _/_(�� Additional Commen s: If Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final inspection by Date b 1n ❑ Tracy 835-6385 Applicant - Return all copies Environmental ealth Permit/Services 1601 E. Hazelton AvE!1. P.O. Box 2009, Stk., CA 95201 to: FEE BASE A41UNTDUE AMOUNT REMITTED RECEIVED BY0-01144 77 DDATE PERMIT 10. INFO . ,� 9�� J-a 1 4�j I d 10/82 500 EM 13-24 REV. 10/82 14-26