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ly ' APPLICATION FOR PERMIT - i SAN JOAQUIN LOCAL HEALTH DISTRICT " 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3,5/i Telephone (209) 466-6781 d PERMIT EXPIRES 1-YEAR FROM DATE ISSUED DATE ISSUED _W* F (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a.pennit to construct and/or install the work.herein described. This application is made incompliance with San Joaquin County Ordinancg No. 549 for sewage or No. 1862 for well/pump and the Rules and Regu ions of the San. Joaquin kocal Health District. e f r' Job Address pjt i Owner's Name Address _ Contractor's Nam ' De��- Phone License No. z 7Z Phone TYPE OF WELL/PUMP WORK; NEW WELL ❑ WELL REPLACEMENT DESTRUCTION j PUMP INSTALLATION _ A d SYSTEM REPAIR ❑ RC1 DISTANCE TO NEAREST: SEPTIC TANK ❑ OTHER SEWER LINES t. DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS= a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS Industrial '. _��t . []Open tom El Manteca x, 17 Domestic/Private Dia. of Well Excavation . 0 Gravel Pack Q Tracy Dia, of Well Casing V+ Public � � 9 Other G" ❑ Delia #r Irrigation � -- - Type of Casing- Cathodic Protection Depth i _ Specifications Geophysical f+` - Depth of Grout Seal U Other A. 'Type of Grout Repair Work Done 'vTypeof Pump H p ` Surface-Seal-Installed Installed by !� State Work Done_ ` ,.Well Destruction U Weil'DiameterSealing Material (top 50') Depth - Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION-U`+REPAIR/ADDITION-* ` {No septic tank or seepage pit permitted�if�pub7ic sewer Installation will serve: Residence Commercialy:Otbpi !^. available within%P-00 feet.) �{A1 Number of living units: Number of e rooms / �• _ lr L'ot�size� X �Q p�,R�-� Character of soil to a depth of 3 feet:- SEPTIC r l� 4- Capacity SEPTIC TANK Water table depth Ej Type/Mfg Ca acit - PKG. TREATMENT PLT. Type/Mfg p y No. Cgmpartmentsy Capacity Method. of Disposal Distance to n'ea'rest: Well : Foundation Property Line LEACHING LIME Ej No. & Length of lines Total length/size FILTER BEDS E] Distance to nearest: Well Foundation l Property Line SEEPAGE PITS Depth p � _-—Si = �^ Number SUMPS _j Distance to nearest- Well Q Foundation pI -"'DISPOSAL PONDS 0 + �, � Pro --L' perty Line s i I hereby certify that I have prepar4 this application and that the work will be done_iri accordance with San Joa On county ordinances, state laws, and rules and-regulIti-on- — the San Joaquini Local Health District. Home owner or licensed agent's signature cer'son the following: "I certify that in the performance of the work for which this 1 Permit to issued, 1 shall not employ any person ins 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 t must c 1 f r all required inspections. Complete drawing on 7gpeverse side. 1 Signed X 71z-el. yy� Title: , Date:f 1/[-G i 'µ OR DEPARTMENT USE ONLY App7 ' ation Accepted by f Area U I Additional Comments: El 5tk 466-6781 Pit or Grout Inspection Lodi 369-3621 l Date Manteca 823-7104 i Final Inspection by Date Applicant - Return all copies to: Envir mental Health Permit/Services 1601E Hazelton Ave., P.O.fiBoxy2009355tk85 CA 95201 I FEE BASE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. $ EH 13-24 REV. 10/82 I4-26 10/82 Soo _. t