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APPLICATION FOR PE RMiT :;�{{_i�fe MPERMIT SAN JOAQUiT: LOCAL -E LTH D15 CT1601 E. HAZELTON AVE., STOCKTON, CA �� N0. Telephone (209) 466-6781- DATE ISSUED t0 PERMIT EXPIRES I YEAR FROM DATE"I It.:ALfH D��1 � TL (Complete in Triplicate) Ij� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ''r. 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 ln,ioa qu'„n Local Health District, Job Address C_ Subdivision Name. Owner's Name Address �Q( Phone Contractor's Name ense No. Phone'4&3- TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ THER T PUMP INSTALLATION ❑ SYSTEM REPAIR 0 L^I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE G FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IJ in strial ❑ Open Bottom Manteca Dia. of Well Excavation omestic/Private Gravel Pack [fTracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Approx.Irrigation R Eastern g PP ❑ Specifications Cathodic Protection Depth Depth of Grout Seal ❑ Geophysical Type of Grout ❑Other Surface Seal Installed by QLLS"fs-:I) H P State Work Done Repair Work Done Ty -e Ramp Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 01 f Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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:--- Number of bedrooms Lot size Character of"soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [f Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ED I.. 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 became subject to workman compensation laws of California.” Contractor's hiring Dr sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." The applicant ust call fog` 1 required spectio s. Complete drar7l on reverse, side. /� f�� 1 Signed X 1 .sv��(✓/ Date: T ��'d 0 PA T ONLY i Application Accepted by Rrea Q Z Stk �66-67 " Additional Comments: E] Lodi 369-3621__1 69-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by _ _ Date l0-4_ Y3 L Tracy 835-6385 Applicant _ Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOlb� T EH 13-24 REV. 10/82 10/82 500 14-26 k