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y APPLICATION,FOR PERMIT SAN JOAQU'IN LOCAL HEALTH DISTRICT I ` 1601 E, HAZI_LTON AVE., STOCKTON, CA PERMIT NO. 3~ 5 3 Telephone (209) 466-6781 DATE ISSUED S PERMIT EXPIRES I 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 Regulat'ons A the San Joaquin Local Health District. Job Address ivision'Name Owner's Name Address ! Phone Contractor's Name e - .License No. 30S 7 A/ phone 3 6f-d.5 c TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ w PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE {.i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS lI'' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 111 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth p Depth of Grout Seal ❑Geophysical J _ Type of Grout ❑Other w ��. Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ; Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION 1]?�o 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 �-Z Lot size J9.ad.A,t , Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg A%A. Capacity No. Compartments �— PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well iftt Foundation _ Property Line DESTRUCTION LEACHING LINE No, & Length of lines ,3 �(� ! A+i Total length/size ( � FILTER BED ❑ Distance to nearest: Well Foundatien 1 Property Line 1 SEEPAGE PITS Depth ` N Numter _ SUMPS L_I Distance to nearest; Well:124 Foundation J2 Property Line t DISPOSAL PONDS ❑ (j.J� " Ct S t 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-fol Iowing:, "I,certi`fy thatri.n the performance of'the work for which this permit is issued, 1 shall not employ any person'"in such manner as to become subject to workman compensation laws of California." Contractor's hiring or suh-contracting signatur.'e"c'ert'ifies the fol'lowing;, "I 'certifythat in the performance of the work for which this permit is issued, I shat empl persons subject to workman's compensation laws of California." The applic t ust ca for ed inspections. Complete drawing on reverse side. f Signed X - I Title-:,-1/7, Date: FOR DEPARTMENT USE ONLY Application Accepted by ' *""`P " Area ❑ Stk 466-6781 Additional Comments: ` + Lodi 369-3621 Pit or Grout Inspection b Date LL] Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies o; Environ e tat .Health Permit/Services I60i E41, 11HAve., P.O. Box 2009, Stk., CA 95201 I FEE BASE AMOUNT DUE ` i AMOUNT,,.REMITTED RECEIVED BY 1CDATE o`PERMIT N0: , INFO EH 13-24 REV. 10/82 .. t 10/82 500 14-26