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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. �— / Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED DATE ISSUED I �j �,� (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein 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 f e E Subdivision Name Owner's Name Address Phone 23 -3 Contractor's Name ,43 /t$' License No. Phone 1 TYPE OF WELL/PUMP WORK: NEW WELL Q 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 Industrial EJ Open Bottom Manteca Dia. of Well Excavation 17 Domestic/Private ' []Gravel Pack E] Tracy Dia, of Well Casing 17 Public Lj Irrigation 0 0Cher Delta Type of Casing Approx. Eastern ❑Cathodic Protection Depth Specifications' Geophysical Depth of Grout Seal U Other Type of Grout s Surface Seal Installed by Repair Work Done Type of Pump H:P. State Work Done 4 Well Destruction Well Diameter Sealing Material (top 501) Depth i Filler Material (Below 501) (� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDI710N 1 g (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence K Commercial _ Other available within 200 feet,) Number of living units: _1L__, Number of bedrooms Lot size , �J Character of soil to a depth of 3 feet: �'� Water table depth SEPTIC TANK '�j Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation ` Property Line LEACHING LINE f r' No, & Length of lines -Total length/size v X 7— n,. FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth j7 Size 3 6 �f Number 00" �T i SUMPS L� Distance to nearest: Well bpd 6 Property Line Foundation /O 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 workman.!s 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 applicant must call for all required ec ions. Complete drawin o reverse si _ Signed X - Title / Date: , OF 2-6 Application Accepted by RTM USE ONLY Area r/3-e 3 E Stk 466-6781 Additional Comments: 1 + , �r1 + Lodi 369-3621 � Pit or Grout inspection b e ❑ Manteca 823-7104 Final Inspection by Date `/ — Tracy 835-6385- Applicant - Return all copie to: ' Environmental -Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA '95201] FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFD DATE PERMIT N0. ' EH 13-24 REV. 10/82 V 4 14-26 10/82 1500