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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTR 1601 E. HAZELTON AVE., STOCKTON, C 1`tAR e1 1(;i84 RhiIT N0. Telephone (209) 466-6781 r DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISS 1j N JOAQUIN LOCAL (complete in Triplicate) HEALTH DISTRICT 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 Joaquin Local Health District, Job Address SC_ iv' �� 4�ubdivision Name ' J'J� j/UdTQ d!- Owner's Name j Address i 13 o x lo-3 Phone Contractor's Name 'L License No. 1219010 Phone �7 oQ TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ p n PUMP INSTALLATION SYSTEM REPAIR OTHER L1/a� L 70 b-e S" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE ow 41. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE �_ri TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial i U Opeh'Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private Gravel Pack Tracy Dia. of Well Casing Publ is..-.-,-.....-r-..._------�-�-�Other"".. ----�❑ Del to - -._.__. .�-...-._..---. Type of,Casing Irrigation Approx. ❑ Eastern Cathodic Protection Depth Specifications Depth of Grout Seal.- { Geophysicalr �. Type of.Grout T ,. ❑Other t y Surface !Seal Installedby;' Repair Work Done Type of ump H.P. '� n" --'-State Work Done �• /; Well Destruction ❑ Well Diameter Sealing Material (top 50') .� Depth Filler Material (Below 50') -4YPE ,OF .5EPTIC WORK:. NEW INSTALLATION REPAIR/ADDITION j j (No septic tank or seepage,pit permitted if public sewwer is L--— - available within 200 feet.) Installation 'will serve:_ Residence Commercial _ Other Number„of living units: * Number of bedrooms Lot size Chb'racter-of soil to a`depth 'of'3 feet” " Water table depth , l SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Bell 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 e I Depth Size Number SUMPS LQ, Distance to nearest: .Well Foundation 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 as 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 this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applica ust 11 for ao requir d inspections. Complete drawing on reverse••side Signed X Title: . , e A: Date: LlJ FOR DEPA ENT USE 0 L� Application Accepted b / Areatk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by/� �" Date Manteca 823-]104 Firal Inspection by c` O- 4. � _� Date {� Tracy 835-5385 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 � r� � 10/82 500 14-26 `�fj