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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT NO. %2 DATE ISSUED 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�fthe San �loaquin Local Health District. Job Address �.I// Subdivision Name Owner's Name r Address Contractor's Name License No. L �,� Phone TYPE OF WELL/PUMP WORK: NEW WELL PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION INTENDED USE TYPE OF WELL .Industrial F! Open Bottom ❑ Domestic/Private ❑ Gravel Pack ❑ Public ❑ Other Irrigation A rox. [Cathodic Protection Depth ❑ Geophysical ❑ other s Repair Work Done ❑ Type of Pump Well Destruction Lf Well Diameter Depth WELL REPLACEMENT [] DESTRUCTION ❑ ❑ SYSTEM REPAIR OTHER ❑ _ SEWER LINES DISPOSAL FLD. AGRICULTURE WELL OTHER WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Dia, of Well Excavation Tracy Dia, of Well Casing ❑ Delta - Well Foundation Type of Casing Eastern Specifications { Depth of Grout Seal ' Type of Grout a Surface Seal Installed by H.P. State Work Done Sealing Material ` (top 50') Filler Material (Below 50') PROP.. LINE PITS/SUMPS TYPE OF'SEPTIC W6RK: NEW INSTALLATION Dg�REPAI�DDITION ❑ (No septic tank or seepage pit permitted if public sewer is e ° t � V" available within 200 feet.) Installation will serve: Residence �' Commercial _ Other Number of living units: Number of bedrooms Lot size Character of soil to depth of 3 feet: %� ` ; Water table depth SEPTIC TANK Type/Mfg. ' 'Capacity No. Compartments Z— PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Methodtiof Disposal SEWAGE SYSTEM Distance to nearest; Well; oundatian }, roperty Line DESTRUCTION ❑ a ."�:>��DP _ __, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED stance to nearest: Well Foundation , Property Line SEEPAGE PITSDepth Size Number A SUMPS Distance to nearest: Well Foundation Property t4, DISPOSAL PONDS ❑ F r• 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 far which this permit is issued, I shall not employ any person in such manner as to become subject to workmans 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, 1 shall employ persons subject to workman's compensation laws of California." The applican st call for a re ired inspections. Complete dr, 'ng on reverse side. Signed X Title: Date: � s FOR DEPARTMENT USE ONLY ~ Application Accepted by ONLY Area �f Stk Additional 1- Additional Comments: Lodi 369-3621 Pit or Grout Inspection Datec? LJ Manteca 823-7104 Final Inspection by X19 Date V 0 (5'a ❑ Tracy 835-6385 Applicant - Return all topic to:. Environmental Health Permit/Services 1601 E. azelt Ave., P.Q. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE INFO S, it, o EH 13-24 REV. 10/82 14-26 AMOUNT REMITTED I RECEIVED BY DATE i PERMIT NO. IZ3 10/82 500