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i �. APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Applicatior. 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 it 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. hh �., Job Address�l`,��_ ]F,i.e.�cC•.'b. � , � subdivision Name M Owner's Name Address Phone Contractor's Name } 1�- Ln�t/ � License No. e2z b341 Phone -q _11III _ TYPE OF WEL /PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR OTHER } /1L.�3 �''�'�' Ly DISTANCE TOiNEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS lndustrial U open Bottom 71 Manteca Dia. of Well Excavation U Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing i] Public r-1 Other ❑ Delta Type of Casing E Irrigation Approx. F1 Eastern ❑ Cathodic Protection Depth Specifications �I Depth of Grout seal Geophysical Other � Type of Grout U (� Surface Seal Installed by Repair Work Done Type of Pump H.P. � . State Work Done U � � Well Destrucftfion LJ Well Diameter Sealing Material (top 50') 1 I; Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is q�l available within 200 feet.) 1 Installation will serve: Residence Commercial Other W Number of1'Iiving units: Number of bedrooms Lot 'size �- Charactel'of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUDTION LEACHING LINE U No. & Length of lines Total length/size FILTER BEDI Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number i SUMPS I:. L— Distance to nearest: Well Foundation Property Line DISPOSAL-PONDS IIM' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances'111state 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's compensation laws of California." Contractors 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 m st 11 fo 1 required inspections. Complete dr on reverse side. Signed x i1�l > �f1__ � Title: Date: j FOR EPARTMENT USE ONLY Area l,3 [] Stk 466-6781 Application Accepted by Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date j?-IM a n t e c a 823-7104 Final Inspection by Date q_ Tracy 835-6385 Applicant IT Return all copies 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. EH 13-24 iREV. 10182 10/82 500. 14-26