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�..•-�-/� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E. HAZELTON AVE., STOCKTON,,CA PERh1IT NO. Telephone (299) 46fi-6781 z'. DATE 155UED�43 Y PERMIT EXPIRES 1 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,Re of be San Joaquin Local Health District- and !y. ubdivision Name Job Address `( Addss Phone Owner's Name D Phone Contractor's Name icense No. -- TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION CJ W PUMP INSTALLATION SYSTEM REPAIR OTHER U 4 DISPOSAL FLO, PROP. LINE SEWER LINES ❑l OI5TANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` 1 iNTENDEO USE TYPE ,OF, WELL, PROBLEM AREA CONSTRUCTION SPECSFICATIONS W Industrial - ' [—I Open Bottom � Manteca Dia. of Well Excavation LJ Domestic/Private [] Gravel Pack • [—I Tracy Dia. of Well Casing Public [10therE].Delta Type of Casing ,u Irrigation Approx. Eastern Specifications ❑Cathodic Protection Depth,}: Depth of Grout Seal Geophysical Type of Grout, •,U Other , Surface Seal Installed by Repair Work Done AType of Pump H.P. State Work Done SealingMaterial (top 50') Well Destruction L} Well D'iamefer Depth Filler Material (below 50') i I� TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is / available within 200 feet.) Il Installation will serve: R sidence i�C Commercial Other / E Number of living units: Number of bedrooms _ ' Z Lot size Water table depth � - Character of soil to-a dept of 3 feet: No. Compartments �-- T e Mf Capacity I�Q SEPTIC TANK TANK yP / 9 K Method of Disposal PKG. TREATMENT PLT. [] Type/Mfg Capacity t ISEWAGE SYSTEM Well j fZj Foundation Distance to nearest: Ml U Property Line �I~� DESTRUCTION ' LEACHING LINE No. & Length of lines ill�ingth/size FILTER BED Distance to nearest: Well Foundation Property Line'Y Aepth Z� Size to Number SEEPAGE PITS - ' Distance to nearest: Well Foundation Property Line SUMPS L—I !' DISPOSALA PONDS[, CI I ` lication and that the work will be done in accordance'with San Joaquin county I hereby certify that I have prepared this app ordinances, state laws_and rules and regulations of the San,Ooaquin Local Health District. -Home owner or licensed agent's signature certifies suchfman�ernas to become subjectntohworkmank compensaterformance of lionwlaws fof California." permit is issued, I shall noL employ any. p Contractor's hiring"'or-'sub-contracting signature certifies the fall"owing: "I certify that in the performance of the work for whit this permit is issued, I sh employ ersons subject to w6rkman's compensation laws of California." The app t ^call f 1 inspections. Complete drawing on reverse side`s J j �� Date: 7` Signed Title: F DEPARTMENT USE ONLY 2 �Stk 466_67$1 { Area �� � Rpplicati'on Accepted by /�T � � � , Jvd �it� Lodi 369-3621, Additional Comments: Doi r Manteca 823-7104 Date Pit or. Grout Inspection i ❑ Tracy 835-6385 1=� � Date Final Inspection by Applicant - Return all copie t Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 f PERMIT ND. DATE FEF BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY r I ? INFO � � � 4; 10/82 500 EH 13-24 REV. 10/82 , �. � �•' ti 14-26