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F i t t APPLICATION EOR,.PERMIT ��\ 1 SAN JOAQUIN'LOCAL'HEALTH DISTRICT �I 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209)466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t 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 Re9 ulations"of the an Joaqjn Loc.4 H District. Job Address �L Sub Owner's Name � Address Phones- Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: ik NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ BOTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD: PROP, LINE FOUNDATION ti AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a r U Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing -� ❑ Irrigation i� Approx. ❑ Eastern Depth Specifications ❑ Cathodic Protection h Depth of Grout Seal ❑Geophysical ❑Other Type of Grout Surface Seal Installed by FRepair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction-C] Well Diameter Sealing Material (top 50') _ Depth i, Filler-Material (Below 50') i r r =TYPE OF SEP_T.IC.WORK,NEW.hNSTALLATION� REPAIR/ADDIT-i ON ❑ (No septic tank or seepage pit permitted if public sewer is r 3 I s =; available within 200 feet,) n\ Installation will serve: Residence Commercial Other ? t Number of living units: Number,of bedrooms Lot size �f' Character of soil ,to a depth of 3 feet:' ` '""" ' "" `t I Water table depth ISEPTIC TANK ❑' TyPe/Mfg Capacity Id 10 10 No. Compartments 1PKG."TREATMENT PLT. ❑ Type/Mfg,,_ Capacity ( Method of Disposal ;SEWAGE SYSTEM Distance to"nearest: Well I � Foundation Property Line DESTRUCTION Q .di ° n. f ,. �+• i LEACHING LINE WU No ; & Length ofi lines ' ) Total length/size P / FILTER BED Distance to nearest: WellFoundation ,,f? Property Line /O a SEEPAGE PITS ❑ Depth •�- ) Size 3 Number 4v SUMPS I Lj Distance to nearest:; Well 1 Foundation Property Line _' DISPOSAL PON©$" ❑_'....'w+l! II hereby-certify-that-h,have- -pared-this application and that the work will be done in accordance with San Joaquin county v 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 ipermit is issued, I lbo 1 not employ any person in such manner as to become subject to workmans compensation laws of California." ;Contractor's hiri sub-contracts signature certifies the following: "I certify that in the performance of the work for which this permit is ued, I sha111.l,;n persons•subject-:to workman's compensation laws of California." The applicant t call. r:,-a' a Ycticr6, ,complete"drawing reverse side. "Signed X Title: Date: 1 OR DE MENT USE ONLY , € Application Accepted by ry' tl I Area6,7 ❑ Stk 466-678 Additional Comments: « ❑ Lodi 369-3621 Pit or Grout Inspection by t Date ❑ Manteca 823-7104 { Final Inspection by ` Date, _._Z_ ❑ Tracy 835-6385 Applicant - Return all copies to: Environmen ealth Permit/Services 1601 E. Hazelton Ave., P.D. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT 'REMITTED_ RECEIVED BY DATE PERMIT N0. i -INFO,.- - � � YY r• EH 13-24 REV. 10/82 y 10/82 500 1 14-26 _ a