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APPLICATION FOR PERM17 , SAN JOAQUIN LOCA! HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 � 'DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) p l [ 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 ofthb San Joacuin L a Health District, Job Address )� �,: Subdivision N e �T Owner's Name �f. dress /�E7 I Phone Contractor's Name ` nse No. Phone �� Y �"✓I �' ^� TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO• PROP. LINE i FOUNDATION�7 AGRICULTURE WELL OTHER WELL PITS/SUMPS T i' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I�` .❑ Industrial - U Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing ❑ Public ❑ 0ther ❑Delta Type of Casing V Irrigation Approx. ❑Eastern Specifications Cathodic Protection Depth ' Depth of Grout Seal Geophysical ❑Other r Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction F-1 Well Diameter Sealing Material (top 50') Depth ( Filler Material (Below 50') f TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is I J 1 available within 200 feet.) Installation will serve: Residence x Commercial Other 1. R) Number of living units: Number of bedrooms _ Lot size Character of soil to a depth of 3 feet: ;'•.: _ ?'Water table depth !- _ SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg `'fo `Capacity �'*+ { Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. &`Length of lines ` Total.-length/size FILTER BED ❑ Distance to nearest: Well 4 , Foundation- ' �P.ro`perty-Cine' - ti.. p. fig SEEPAGE PITS � Depth � Size 6 f/r 44' '4. ''Number.. SUMPS ❑ Distance to nearest: Well 00 ,Foundation /O Property Line 4 . t• DISPOSAL PONDS ❑ rtT--w-��- - U -�....--T-.-_ I hereby certify that I have prepared this application'l od that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of�ti•Ii�, San Joaquin Local Health District. he fo Home owner or licensed agent's signature certifies tllowing: "I certify that in the performance of the work for which this M permit is issued, I shall not employ any person in such manner as to become subject to workmant 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 4t J ed inspections. Complete drawing on reverse side. .9 Signed X �/ Title:, V 4 -- _ Date: -"-r,.�CIR DEPARTMENT USE ONLY Applic tion Accepted by ! �` Area — ❑ Stk 466-6781 x Additional Comments: Lodi 369-3621 . Pit or Grout Inspectionb Date ❑ Manteca 823-7104 Final Inspection by t'.^ Date ❑ Tracy 835-6385 Applicant - Return all copies o: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASF AMOUNT i DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. 4 INFO EH 13-24 REV. 10/82 10/82 500 14-26