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APPLICATION FOR PERMIT SAN JOAQI iN LOCAL 'HEALTH DISTRICT r� Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q 47(/ -- Telephone (209) 466-6781 DATE ISSUED 11423 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 wellipump and the Rules an Reguullations o e San,Joaquin Local Health District. Job Address 5 Subdivision Name Owner's Name Address Phone Contractor's Name �f License No. Phone TYPE OF WELT/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IFl Industrial U Open Bottom Manteca Dia. of Well Excavation F—IDomestic/Private 7 Gravel Pack ❑ Tracy Dia, of Well Casing Public Other Delta Type of Casing u Irrigation Approx. [] Eastern Specifications Catoc Protection Depth ❑ hdiPttiDepth of Grout Seal Geophysical Type of Grout Lf Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done I� Welt Destruction Well Diameter Sealing Material (top 50') Depth _69 Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 71 REPAIR/ADDITION j l (No septic tank or seepage pit permitted if public sewer is V available within 200 feet.) 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 Fj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that 1 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 workmanly 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 applicant call f al required inspections. Complete drawing n reverse side. Signed X le: S Date: R RTMENT USE ONLY Stk 466-6781 Application Accepted b Area Additional Comments: Lodi 364-3621 Pit or Grout Inspect! n y Date ��j � Manteca 823-7104 Final Inspection by Date $� Lj Tracy 835-6385 Applicant - Return all cop a to: nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY (DATE Q 7PERMIT NO. INFO + V_6 �_ +� � ! � Bj O J f 10/82 500 EH 13-24 REV. 10/82 14-26