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z- APPLICATION FOR PERMIT SAN JOAQUII: LOCAL HEALTH DISTRICT !' 15CI E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 1 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED �� (Complete in Triplicate) Application is h�reb 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 far well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .Z Subdivision Name Owner's Name Address (jJG�-y Phone Contractor's Names �rca License No. e��yg ,/ Phoneme-3� TYPE OF WELL/PUMP WORK: NEW WELL *" WELL REPLACEMENT ❑ DESTRUCTION ❑ w W PUMP INSTALLATION SYSTEM REPAIR L7 OTHER 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 CONSTRUCTION SPECIFICATIONS, � ❑ Industrial U Open Bottom ® Manteca Dia. of Well Excavation Domestic/Private J Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑J Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications ❑ Depth of Grout Seal Geophysical Other Type of Grout Surface Seal Installed by Repair Work Done [:] Type of Pump p H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501) _ 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: �'4 Number of bedrooms Lot size Character of soil to a depth of;3 feet: Water table depth SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments T` PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑l Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 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 this permit is issued, I shall employ persons subject to workman's compensation laws of California." Theapplica st ca 11 ora 1 e ired A spections. Complete drawing on reverse side. f 7 Signed X ! Title: Date: 1 �J FO$ DEPART Application Accepted by Area E] Stk 466-6781 Additional Comments, ❑ Lodi 369-3621 Pit or Grout Inspection by rn 1l ,., 1 Date Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: ironmental Health Permit/Services 1601 E. Hazelton P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO a { 1 -9: — 426 EH 13-24 REV. 10/82 10/82 500 14-26