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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES i YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate') Application is hereby made to the San described. This application is Joaquin Local Health District in for a permit to construct and/or install the work herein and the Rules aqg made Regulations compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ❑ Gravel Pack of the San Joaquin Local He ith A stri PublicOther [jE] Delta Job Address Lj Irrigation z h[ 4,Q S -v u ,visior 4. Name Type of Casing 7` Cathodic Protection Owner's Name 7`% Address 17 Geophysical Final Inspection by Date f.1 ,� f� le., e. *A2 Phone -2 V Q 835-6385 Applicant - Return all copie to: Contractor's Name P.O. License No. ; Stk., CA 95201 s. :. Phone 3-3 :=p .7 9Q TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT State Work Done DESTRUCTION Well Diameter Sealing Material PUMP INSTALLATION SYSTEM REPAIR Depth SQ OTHER LJ (Below 50') (�",& A,e,4,,fx 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 I J Industrial U Open Bottom Manteca Dia. of Well Excavation U, Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing PublicOther [jE] Delta Additional Comments: Lj Irrigation �+� %A /) pprox. ❑ Eastern Type of Casing 7` Cathodic Protection Depth Specifications P 17 Geophysical Final Inspection by Date f.1 ,� f� le., Depth of Grout Seal FfOther 835-6385 Applicant - Return all copie to: Type of Grout P.O. Box 2009, Stk., CA 95201 Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material (top 501) Depth SQ Filler Material (Below 50') (�",& A,e,4,,fx TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/,ADDITION ❑ (No septic tank or seepage Ipit permitted if public sewer is Installation will serve: Residence C available within 200 feet.) ommercial Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: SEPTIC TANK F) Type/Mfg PKG. TREATMENT PLT. E]- 'Type/Mfg SEWAGE SYSTEMDistance to nearest: Well DESTRUCTION Q — LEACHING LINE iJ No. & Length of lines FILTER BED Distance to nearest: Well Other Lot size Water table depth Capacity No. Compartments Capacity Method of Disposal Foundation Property Line Total length/size Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well Foundation .Property Line 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 workmant 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 i issued, I shall employ persons subject to workman's compensation laws of California." The appli nt'm st call for all uired'inspections. Complete drawing on reverse e Signed X Title: Date: / 2-/ { R DEPARTMEN NLY ya / Ap cation Accepted by rea _ �� ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date f.1 ,� f� le., Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 16011—E--.. Hazelton P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE INFO ro,mo AMOUNT REMITTED I RECEIVED BY 1 DATE I PERMIT NO. EH 13-24 REV. 10/82 Q_W� 10/82 500 14-26