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APPLICATION FOR PERMIT n SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. fj �J Telephone (209) 466-6781 DATE ISSUED 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 Regulati ns/}o.�f.�the San Joaquin Local Health District. ,---I Publ is 0th D 1* Job Address - 477VA.1I Subdivision Name Distance to nearest: Well Foundation Property Line Owner's Name Address ? i ; hl�f �% hone Contractor's Nam � � } (�( License No. � �� 0 L Phone TYPE OF WELL/PUMP WORK: NEW WELL EJ WELL REPLACEMENT DESTRUCTION PUMP INSTALLATIONSYSTEM REPAIR 1] OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA J Industrial U Open Bottom Manteca F—IDomestic/Private ❑ Gravel Pack ❑ Tracy ,---I Publ is 0th D 1* CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia. of Well Casing _ er ❑ e a Type of Casing V Irrigation Approx. Eastern Specifications 7 Cathodic Protection Depth Depth of Grout Seal I--] Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done D Type of Pump cz,,� H. P. per. State Work Done Well Destruction U Well Diameter Sealing Materia (top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK EJ Type/Mfg PKG. TREATMENT PLT. Type/Mfg SEWAGE SYSTEM 11-� Distance to nearest: Well DESTRUCTION U Other Lot size Capacity Capacity Foundation Water table depth No. Compartments _ Method of Disposal Property Line LEACHING LINE U No. & Length of lines Total length/size FILTER BED INFO Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 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 workmanis compensation laws of California." Contractor's h' ii or sub-contractin si nature rtifies the following: "I certify that in the performance of the work for which this permit i i sued, I Shall yem��Yop',�ons su jectto workman's dmpensation laws of California." The applica m t call Fo °al)nspe ions. Complete a ing oo//n reverse side. Signed X (��Title: �I Dater' f FO EPARTMENT LY �� L'/ Application Accepted by Area '9 1 Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date Manteca 823-7104 Final Inspection by / O �' Cc � Date ! Y L Tracy 835-6385 Applicant - Return all copies to: Environmen 1 Health Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, Stk., CA FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO Ok EH 13-24 REV. 10/82 14-26 95201 10/82 500