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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA / PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) a 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 Regulation of the San Joaquin Local.Health District. Job Address �'r �' Q � �L Subdivision Name Owner's Name d Address Phone Contractor's Name S License No. Phone SFr 9607 'P TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT ❑ ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca pia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other [�Delta Cj Irrigation Type of Casing Approx. � Eastern ❑Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal L-10ther Type of Grout Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done (} , Wel] Destruction ❑ Well Diameter Sealing Material (top 501) h� Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONse � � (Na septic tank or seepage pit permitted if public sewer is Installation will serve: Residence fe Commercial _ Other available within 200 feet.) Number of living units: _( Number of bedrooms �:3 ` Lot size _ p Character of soil to a depth of 3 feet: C Water table depth �p SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. �] Type/Mfg Capacity Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. A Length of lines OOF op, Total length/size Z FILTER BED ❑ Distance to nearest: Well Foundation 3,0 Property Line /c ` SEEPAGE PITS Depth gX Size y Number SUMPS ❑� Distance to nearest: Well Foundation 3(/ ' Property Line /C / DISPOSAL PONDS ❑ ' 0 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 workmanh 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 applican ust �,a for allXgquired ' pections. Complete drawi on�verse Signed _ Title: ti 1Date: PA Application Accepted by F DERTMENT USE ONLY-&-L- Area Q [� Stk 466-6781 Additional Comments: El Lodi 369-362.1 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,' CA 95201 FEE INFO BASE AMOUNT DUE;,` AMOUNT REMITTED 'RECEIVED BY DATE PERMIT N0. 8 EH 13-24 REV. 10/82 14-26 10/82 500