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APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HE4LTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 GATE 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 Regulations of. the San Joaquin Local Health District, Job Address Subdivision Name. Owner's Name Address . Phone Contractor's Name License No. t)9,031 Phone 17 TYPE TYPE OF WELL/PUMP-WORK: NEW WELL WELL REPLACEMENT DESTRUCTION L] 1 PUMP INSTALLATION SYSTEM REPAIR L!"r OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE g FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }}} Industrial _ U Open Bottom . ] Manteca Dia. of Well Excavation U Domestic/Private' _F-1 Gravel Pack Tracy Dia. of Well Casing j 17�Public F7� Other Delta Type of Casing V,Irrigation Approx. Eastern Cathodic Protection Depth Specifications r Depth of Grout Seal El'Geophysical �, Type of Grout -0ther U i Surface Seal Installed by 4Repar Work Done State State Work DonNA9&z& �{�( 1 Wei 11 Destruction Well;Diameter �Sealing Materia (top 50') ! DeptP rh Filler Material (,Below 50') ; T v, ,'NP-E OF SEPTIC WORK: NEW INSTALLATION,U, RFPRIR/AODITION j fJ j(No septic tank or seepage pit permitted if public sewer is ► _, ;;_ available within 200 feet,) r' Installation will serve: Residence Commercial _ Other \_.ti, t Number of living units: Number of bedrooms I Lot size � - Character of soil to a_depth-off 3-f-eet;,-.---- - »-M 1 Water table depth <. PTIC TANK E] Type/Mfg i Ca-facity No. Compartments 4j, � `PKG. TREATMENT PLT. E] Type/Mfg a Srpacity Met Disposal-,4 K SEWAGE SYSTEM Distance to nearest: Well �.Fo'uhdaition Property Line 1 . 4'....' . I DESTRUCTION VA a.,igk,;tom:,�. If .LEACHING LINE ❑ No. & Length of lines Total length/size IFILTER_BED._ D,,,a,,Distance to nearest: Well Foundation Property Line SEEPAGE PITS rj Depth .; ; ?J5iZ- j! Number T r^SUMPS _ Lj Dlstance,toinearest: Well Foundation Properfy"Line`— DISPOSAL PONDS ❑ -r . � - ._� . -_ - s .._F..,T �_,-,mi=x t � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county j 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 workmant 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 Ythis permit is issued, It Ishall ploy persons subject to workman's compensation laws of California." 'The appliG t st call ora 1 eq u' edrinspections. Complete draw' 'g on r verse side. Signed X Title: Date: r y ^ S FOR PARTMENT USF ONLY � Rp icator ion Accepted by Area - _ tk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date L] Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. INFO EH 13-24 REV. 10/82 10/82 500 I 14-26 )