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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL`'HEALTH DISTRICT 1601 E. HAZELTON,AVE., STOCKTON,�CA�� L ) PERMIT NO. Telephone-(209) 466-6781 p DATE ISSUED PERMIT EXPIRES'1 YEAR FROM DATE'ISSUED l- r1 4 , (Complete in Triplicate) Z'' ,, 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/gnd Regulations of the San Joaquin Local Health District. ' Job Address Subdivision-Name r Owner's Name Address Q ,Phone "k Contractor's Name /rti s' License No,. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIONS SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP.--LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE�OF WELLr, PROBLEM AREA m CONSTRUCTION SPECIFICATIONS-_ _ Industrial ❑ 0pen Bottom' [] Manteca Dia. of Well Excavation Y },Domestic/Private ❑Gravel Pack 0 Tracy Dia, of Well Casing 0 Public F-jOther Delta Irrigation Type of Casing U 9 Approx. [] Eastern Specifications Cathodic Protection Depth Geophysical Depth of Grout Seal W Other Type of Grout W Surface Seal Installed by Repair Work Done ❑ Type of Pump ��,� ^ H.P. State Work Done j Well Destruction ❑ Well Diameter Sealing Material (top 501) — 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 2DO feet.) G 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 Ej Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. EJ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION C3 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest, Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS LJ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, I hereby certify that I have prepared this application and that the work will-be'done in accordance with San Joaquin county s 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 workmank 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 applic must call f all required inspe ns. Complete drawing on reverse ide. Signed X Title: /V Date: _ R DEPARTME USE N y' App ication Accepted Stk 466-6781 Additional Comments; ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by 2>5Date �. ❑ 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. INFO EH 13-24 REV. 10/82 10/82 500 14-26