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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -�Z Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I 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 Distric Job Address 104/ s� Owner'sIF r- Nameddress �d�i// �, tgr_ �rPhone J� ' Contractor's Name ` License No. � ��acf- w Phone��r [y�� L TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 i Industrial ❑Open Bottom ❑Manteca Dia..- of Well Excavation Domestic/Private F-1 ❑Gravel- Pack ❑Tracy. Dia: of Well Casing ❑Public ❑Other ❑Delta Type of Casing Irrigation Approx. ❑Eastern Depth Specifications ❑Cathodic Protection p Depth of Grout Seal ❑Geophysical Q Type of Grout ❑Other Surface Seal Installed by Repair. Work Done ❑ Type of Pump H.P. State Work Done - r Well Destruction ❑ Well Diameter Sealing Material (top 50') DepthFiller Material (Below 50') ' TYPE 'F SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION (No septic tank or seepage pit permitted ifpublic sewer is available within 200 feet.) lnstallation will serve: Residence A[ Commercial _ Other Number of living units: Number of bedrooms 7r Lot size f. Character of soil to a depth of 3 feet: A!L*- Water table depth /Q i SEPTIC TANK U Type/Mfg .Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal c__ SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line (- DESTRUCTION ❑ LEACHING LINE No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: Well' s Foundation M r Property Line /19 ' SEEPAGE PITS Depth "�� Size Number Ii } SUMPS Distance to nearest: Well Foundation �pProperty Line fE? DISPOSAL PONDS ❑ rb I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county l 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 became subject to workmanh.compensation laws of California." { Contractor's h'ring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i issued, I shall em 10 Pers subject to workman's compensation laws of California." The appli t tail f all r red ns d o Comple�e a� n reverse side. Signed x Title: Date- ' TM ENT ONLY Application Accepted Area --�C?i— ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 I Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copi s t@ o: . Environmental Hea h 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 _ . oan, a� i EH 13-24 REV. lb/82 10182 500 14-26 "