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APPLICATION FOR PERMIT SAN JOAQL'iN LOCAL HEALTH DISTRICT �� y 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Y Telephone (209) 456-6781 ---��j PERMIT EXPIRES 1 YEAR FROM DATE I$$0£D 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 d u }o�s of ean aq in Lo Sealth District, Jab Address ''�/fl�� Subdivision Name Owner's Nameress Phone Contractor's ame License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC,TIC N ❑ F. 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 I f Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Depth � Specifications- - -� ❑ Cathodic Protection Depth of Grout Seal ❑Geophysical ' Type of Grout Other Surface Seal Installed by , Repair Work Dane ❑ Type of Pump H.P. r State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.AODITIONJK (No septic tank or seepage pit permitted'if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms _ _ Lot size ] ,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 SEWAGE SYSTEM Ei Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. & Length of lines Total ler?gth/size FILTER BED ❑ Distance to nearest: Well f)Q�on —_E__ — Property Lineo - _ SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that-the work will be done in accdrdance 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 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 applica s ll 0, al CJq ired inspe t' s. Complete drawing on reverse side. WI Signed Kfff Title: Date:�PARTMENT USE ONLY l ❑Application Accepted by URrea 1� Stk 46fi-6 Additional Comments: ,t �,.e r ❑ Lodi 369-3621 Pit or Grout Inspection Date Manteca 823-7104 Final Inspection by Date -Tracy 835-6385 Applicant - Return all copies to: Environm 'Health Permit/Services I601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY -7 r DATE-Q -9 PERMIT N0. INFO t I<Lc Jyr 1 13 (A ) Q EH 13-24 REV. 10/82 10/82 500 14-26 w-»-