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l 4 1 T APPLICATION FOR PERM. SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 2 9 1983 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _ r Telephone (209) 466-6781 n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCATE ISSUED 1 (Complete Trips. - ) HEALTH DISTRICT O0 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 Subdivision Name p J Owner's Name Address 2��-4Ct � i� y�s� Phone ^3 Vol? Contractor'$ Name c`' License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ^ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER '��lefl�.[. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR P. LIN t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing Public Delta C ��-- ❑ Other ❑ Type of Casing ,Irrigation Approx. ❑ Eastern Specifications Cathodic Protection Depth � ❑ roDepth of Grout Seal (❑Geophysical Type of Grout ❑)Other �^ Surface Seal Installed by Repair Work Done [K Type of Pump 1A" H.P. j4,0 State Work Done . Ld -40 Well Destruction F-1WellDiameter Sealing Material (top 50') ` r _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line T DESTRUCTION ❑ n LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 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 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 applicant ust cal/"r all required inspections. Complete dr ing on reverse side. Signed X rJii1`+ - A Title: } Date: I�— FOR DEPARTMENT USE ONLY Application Accepted byC4L Area Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date ,may Manteca 823-7104 Final Inspection by Date j L�jj 3 ❑ Tracy 835-6385 Applicant - Return all copies to: En ironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 J. FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26