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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 I YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District fora 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. Jab Address,?5 . 0rfcV_7 fldf Subdivision Name Owner's Name �1 Address �� Q Phone Contractor's Name �y License No. 2 8 -7-6 Phone 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 I OTHER WELL PITS/SUMPS w 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 LA Irrigation Approx. ❑ Eastern Q,Cathodic Protection Depth Specifications Depth of Grout seal 17 Geophysical 6 Other Type of GroutL_J 6 Surface Seal Installed by Q Repair Work Done ❑ Type'of Pump H.P. ` State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') L• Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR ADDITION seepage p p public sewer is ❑ / ❑ (No septic tank or see a e it ermined if ! available within 200 feet.) p . Installation will serve: Residence Commercial Other T• (� 1 Number of living units: Number of bedrooms Lot size #e,2e— Character of soil to a depth of 3 feet: _ �' ,G,�, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM DESTRUCTION Distance to nearest:.. Well Foundation Property Line U � s LEACHING LINE ❑ No. & Length of lines. Total length/size FL' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth �'✓" Size Number 7L SUMPSDistance to nearest: Well /QB Foundation /40 Property Line �f� DISPOSAL PONDS CI 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 workman5 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 ; t call 111 required inspections. Complete drawing o reGgrse side. SignedX 1 Title: Date F R PARTMENT USE ONL Applie ion Accepted by ��/� TArea __ ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 I Pit or Grout Inspection by Date f LJ Manteca 823-7104 Final Inspection by _;C:2 Date � L! L7 Tracy 835-6385 me Applicant - Return all copies to: Environnt Health P 60 Permit/Services 11 E. Hazelto AW, P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO S, EH 13-24 REV. 10/82 10/82 500 14-26