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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT ; 1601 E. HAZELTON �3AVE, STOCKTON, CA PERMIT N0. Telephone (209)466-5781 DATE ISSUE 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 Regulations of the.San ]oa in Local Health District. Job Address Subdivision Name Owner's Name Address -Phone i Contractor's Name License No. / �..�, �] Phone Q TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ o� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED, PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� ; Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation V ' Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casirg ❑1 Irrigation Approx. ❑ Eastern ❑ Specifications Cathodic Protection Depth ~ Depth--of Grout-Seal ❑Geophysical Type of Grout U Other Surface 5ea1 .[nstalled by -Repair Work Done E],_ Type of Pump ' H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50'} _ (� Depth Filler Material:(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public—sewer is r� available within,200 feet.) �/ 1 Instal-lation will serve: Residence _ Commercial Other ! �p t 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 I PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line - DESTRUCTION ❑ -'' 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 o ndation l r 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 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 dS 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 a this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant,mc 1 for 1 required inspections: Complete drawingonreverse side. Signed X0 Title: -Date:. Ab E FOR,DEyAATMEfy USE ONLY Application Accepted by Area /-. Stk 466-6781 Additional Comments: izt i' • �.f E] Lodi 369-3621 Pit or Grout Inspection by' Date /� Manteca 823-7104 Final Inspection by Dat<�q AW�j ❑ Tracy 835-6385 - Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.0 Hazelton Ave„ P.Q. Box 2009, Stk., CA 95201 =INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. EH 13-24 REV. 10/82 10/82 500 14-26