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APPLICATION FOR PERMIT . SAN JORQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 . GATE 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 hoe n J aquin ocal Health District. Job Address Subdivision Name Owner's Name + ddress ® Phone Contractor's Name Ce. ludlin?,A License No.�_?IZTj/._L/ _ Phone + L ?JD TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE w FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial U Open Bottom Ej Manteca Dia, of Well Excavation �� W ❑ N U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing _ Public { v" Other ❑ Delta i � � Type of Casing Irrigation Approx. ❑ Eastern Depth Specifications ,_ b t ! ❑ ep Cathodic Protection 1 j Depth of Grout Seal t '-^" Q ❑Geophysical �'' ,� _ _ x _• r i -�=,+----��Type-of-Grout^---�_ € ❑Othei Surface Seal Installed by /� Repair Work Done ❑ Type of Pump H.P. State Work Done Q ? Well Destruction U Well Diameters Sealing Material (top 50') _ # Depth ( Filler Material (Below 501 + TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ (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: .I Number of bedrooms Lot size G Charatter of soil to a depth of=3 feet: Water table depth �n SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal b SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Legth of lines Total length/size FI"LTER -BED 1 I ❑ Distance,to nearest: Well Foundation Property Line 1."SEEPAGE PITS ❑ Depth Size Number SUMPS_S Distance''to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑� 1 hereby certify that I have prepaled 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 sighature 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 sig tore certifies the following: "I certify that in the performance of the work for which this permit is issued, I shZre.lu/jj ploy er ns subject to workman's compensation laws of California." The applican ll fa inspections. Complete drawing on reverse side. 1' C Signed yX Title: Date: 4 OR RTM USE ONLY � Application Accepted by Area ❑ Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by . Date Manteca 823-7104 i Final Inspection by WAA Date ❑ Tracy 835-6385 i Applicant - Return all copies to: nvironmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA1.195201 «*« F -FEE-w -BASE --AMOUNT ,DUE-. AMOUNT REMITTED _ RECEIVED BY DATE PERMIT NO. INFO ,C7 �� 2� �_a I 3 js 3"1 '13-24REV: 10/82 L- 4.- 10/82 500. 14-26 I