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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 3-129 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. � 3 ` 1 ZQ Z Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 t e San.Joaquin Local Health District. Job Address / Subdivision_ Name Owner's Name Address �e� - Phone Contractor's Name License No. 3f ( Phone TYPE OF WELL/ WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTIONE] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL E OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA f ❑ Industrial. ❑ Open Bottom ❑ Manteca ❑ Domestic/Private Gravel Pack [] Tracy D1 CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation _ Dia. of Well Casing ❑ Public LJ Other ❑ e to Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth roecDepth of Grout Seal ❑ Geophysical Type of Grout ❑ Other Surface Seal Installed by Repair Work Done El Type of Pump H. P, f State 'Rork Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material -(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION vr[iSo septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence to-'_ Commercial _ Other Number of living units: _/— Number of bedrooms_ _ Lot size 1 - Character of soil to a depth of 3 feet:�- Water table depth 1d�Q SEPTIC TANK Type/Mfg 1(j®kg dq (sp.,� Capacity No. Compartments 2�... PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well_Q Foundation ..Zr Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total length/size ?IV'_-` FILTER BED ❑ Distance to nearest: Well r Foundation 2 S_ Property Line SEEPAGE PITS Llj + Depth Size Number n^� SUMPS FIDistance to nearest: Well Foundation �Property Line DISPOSAL PONDS ❑ p. eT 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 certifiA—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 appli t mu 1 for all required inspections. Complete drawing on.reverse side: Signed Title: ®ov t1 Date: l% PARTMEN7 USE ONLY �- ❑ Application Accepted by 1 CC,d� Area �_r)— Stk 466-6781 Additional Comments - ,( Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date i 3 ❑ Tracy 835-6385 Applicant - Return all copie to:. Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. box 2009, Stk., CA 95201 FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVE0,8Y DATE PERMIT N0. INF aEj. $3- ! 4Cf Z 10/82 500 EH 13-24 REV. 10/82 14-26 �M rWr�� "l �1 -1 1.3