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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT qZ�Z 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. , 23 Telephone (209) 466-6781 r t DATE ISSUED 4 4 PERMIT EXPIRES I 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 JOagq,in Local Health District. Job Address Subdivision Name Owner's Name �— Address Z. Phone Contractor's Name � License No. Phone � TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT DESTRJCTION W PUMP INSTALLATION SYSTEM REPAIR OTHER Lf / 1 DISTANCE TO NEAREST: SEPTIC TANK —15D _ SEWER LINES DISPOSAL FLD, PROP. LINE 70 ) nl FOUNDATION AGRICULTURE WELL 30 -__ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IndustrialOpen Bottom Manteca Dia, of Well Excavation LL11" / i C T3� Domestic/Private 7 Gravel Pack Tracy Dia. of Well Casing L� Public COther Delta Type of Casing �C / LjIrrigation Approx. Eastern Specifications 43• t L3 Cathodic Protection Depth Depth of Grout Seal Geophysical Type of Grout U Other Surface Seal Installed by K a Repair Work Done Type of Pump =_--a—— H•P• State Work Dane ~3 Well Destruction U Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') C TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pitpermitted ifpublic fseter is available within 200Installation will serve: Residence — Commercial Other ^� Number of living units: Number of bedrooms Lot size (� Water table depth Character of soil to a depth of 3 feet: 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 DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS F—j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line 1 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 must call for all required inspections. Complete drawing on reverse side. Title: JA C, _ Date: Signed X - FOR TMENT USE ONLY J Stk 466-6781 Application Accepted by i Area — l di 369-3621 Additional Comments: Pit or Grout Inspection by Date j�J Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Envir mental Health PermityServices 16 1 E. azelton Ave., P.O. Box 2009, St k., CR 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY l+ `` DATE PERMIT N0. INFO 10/82 500 EH 13-24 REV. 10/82 14-26