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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .k 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ——7S i, Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 the San J aquin Local Health District. Job Address199677-9 Subdivision Name Owner's Name Address Phone l Contractor's Name OJA icense No. Phone �l TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER L�j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "q5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II 1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation "P ❑ Oomestic/Private Gravel Pack Tracy _ Dia.. of Well Casing may• r Public Other Del to Type of Casing Irrigation Approx. Eastern ❑ Cathodic Protection Depth Specifications Geophysical Depth of Grout Seal ❑Other Type of Grout �. Surface Seal lristalled..by Repair Work Done [:] Type of Pump H.P. State Work Done r f Well Destruction ❑ Well Diameter Sealing Material (top 50') yF Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION U,1 REPAIR/ADDITION or (No septic tank or seepage pit permitted if public sewer is f available within 200 feet.) l Installation will serve: Residence Commercial I Other t r r� Number of living units: Number of bedrooms ;"LFt—,i Character of soil to a depth of 3 feet: Water•table depth SEPTIC TANK �j` Type/Mfg C�-y� Capacity ��('f p No. Compartments PKG. TREATMENT PLT. [J Type/Mfg Capacity Method of Disposal. SEWAGE SYSTEM Distance to nearest: Well dation ��Property L'ine,. _ DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Notal length/size F FILTER BED Distance to nearest:� Wetl Foundation Prope'Ly Line SEEPAGE PITS Depth I Size /X / p f Number : t SUMPS y Distance to nearest: Well Foundation Property Line x r DISPOSAL PONDS ❑ _ } x ...g I hereby certify that I have prepared this application and that the work will be done infaccordance 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 t this permit is issued-; I shall employ persons subject to workman's compensation laws-of California." The applicant us all for alonequired inspe ions. Complete drawing on reverse side. ILI Signed X �OR DEPARTMENT USE 0 Title: �.�.! Date: . " �. Y - _ t � Application Accepted by Area [� Stk 466 6781 Additional Comments: SU,ey O•K -- /V, 14kD - __X Area Lodi 369-3621 t Pit or Grout Inspection by 1 6;11 Date -li �� Manteca 823-7104 Final Inspection by '� ` P Date L� Tracy r 835-6385 Applicant - Return all copies to: Environmental, Hea1th_Permi.t/,5er..vices-1il E.... zelton Ave-,_P-..0.._Box..2009, Stk., CA 95201 a FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO LI S o o --7s EH 13-24 REV. 10/82 10/82 500 14-26