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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH.DISTRICT 1601 E. HAZELTON AVE„ STOCKTON, CA �p Telephone (209) 466-6781 PERMIT NO. p�— PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED ai { (Complete in Triplicate) 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, Z Subdivision Name Q E Owner's Name Address Contractor's Name Mc Phone License Na. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESW DISPOSAL FLD. PROP, LINE a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA Industrial CONSTRUCTION SPECIFICATIONS E] Open Bottom E]Manteca Dia, of Well Excavation 0 Domestic/Private ❑Gravel Pack EJ Tracy L] Public Dia, of Well Casing ❑Other ❑ Delta V' irrigation Approx. Eastern Type of Casing ❑ ❑ Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal Other Type of Grout Repair Work Done ❑ Type of Pumpurface Seal Installed by H.P.ypState Work Done Well Destruction [J Well Diameter Sealing Material (top 50`) Depth L Filler Material (Below 50') TYPE OF SEPTIC WORK: UZIAANA NEW INSTALLATION ❑ REPAIR/ADDITION ' (No septic tank or seepage pit permitted if public sewer is i Installation will serve: Residence J_ Commercial Other available within 200 feet.) Number of livingunitsT —` : Number of bedrooms❑ Type/Mfg —' Lot size AGK III Character of soil to a depth of 3 feet: p Capacity - SEPTIC TANK r Water table depth SZ i No. Compartments PKG. TREATMENT PLT. (] Type/Mfg - Capacity �� Method. of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines FILTER BED ► Total length/size k ❑ Distance to nearest: Well Foundation ! Property Line — arc SEEPAGE PITS Depth __ J Size _S SUMPS Number U Distance to'nearest: Well Foundation DISPOSAL PONDS -- Property Line aCa I hereby certify that I have prepared,this application and that the work will be done in accordance with San Joaquin county ' ordinances, state Taws, 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 hi ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit ' i sued, I shall employ ons ect to work 's compensation Taws of California." The applic t --for l re r i ec ns, CompTet n everse side. Signed Title: Date: Application Accepted by DEPARTMENT USE ONLY Area { Stk 466-6781 Additional Comments: Pit or Grout Inspection by ❑ Lodi 369-3621 Date/ �{J El Manteca 823-7104 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' x FEE BASE AMOUNT !DUE AMOUNT REMITTED INFO RECEIVED.BY DATE PERMIT NO. EH 13-24 REV. 10/82 14-26 10/82 500