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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �n _ Telephone (209) 466-6781 DATE ISSUED 41� 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 Local Health District. Job Address o zlQ Subdivision Name Owner's Name Address S Phone Contractor's Name o License Na. 3 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION [J- PUMP PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 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 Specifications Depth Cathodic Protection ❑ Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work,Done [j Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501 , TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 14 (No septic tank or seepage pit permitted if public sewer is D U �Pavailable within 200 feet.) r Installation will serve: Residence � Commercial _ Other _ 0010 Number of living units: _ Number of bedrooms T of size Character of soil to adepth of 3 feet: C4 Water table depth U SEPTIC TANK Type/Mfg .4AZ 1Z I Capacity -- No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg A.. t Capacity Method.of Disposal SjFMjC,Zp,t4K !!�OHDistance to nearest: .iwe1 - Foundat'on Property Line LEACHING LINE No. & Length of line J Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size 3 3 _ __ Number SUMPS ❑i Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 4 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 shall employ persons subject to workman's compensation laws of California." r, I� The applicant must ca.11 for all quire sp ctions. Complete drawin n re rse side. Signed X Title: Date: 7 D""Z-6-B Z--- FO EP ENT USE ONLY Application Accepted by Area O3 Stk 466-6781 Additional Comments: O [] Lodi 369-3621 3 Pit or Grout Inspection by Date � Manteca 823-7104 a Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26 -