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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 46.6-6781 PERMIT EXPIRES 1 YEAR FROM DATEISSUED DATE ISSUED (Complete in Triplicate) t F Application is hereby made to the San Joaquin Local Health District for e 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. 1852 for well/pump and the.Rules an egulatio of the San Joaquin Local Health District. Job Address Z5 �(L+6�ld Subdivision Name [? Owner's Name 1'i Dd "✓% 'tC'.0 S"r Address TJ- -hone Contractor's Namen �� a'��P, .License No. ��, ,;� Phone��r�� d TYPE OF WELL/PUMP WORK: NEWiWELL WELL REPLACEMENT DESTRUCTION 3•.—P.UMP.INSTALLATION,,.[]_—SY.STEM.REPAIR_Q OTHER, ,QJ- _•„ ..-- DISTANCE DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLO. PROP. LINE s FOUNDATION C AGRICULTURE WELL OTHER WELL PITS/SUMPS . F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial Open Bottom El Manteca Dia. of Well Excavation 1 EJ Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public D Other ❑ Delta r " t Ty pe of 'Casing F-71 Irrigation Approx. �Eastern Spec ifica`tons Cathodic Protection Depth t • Geophysical Depth of Grout Seal Other ; Type of Grout 1 Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') _ C E Depth Filler Material (Below 50') 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ( REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is r' available within 200 feet.) ` Installation w.il-1. serve: "Residence Commercial ___ Orrrrther C Number of living units: � Number of bedrooms Lot size Character of soil to a,dept "of 'l3 feeti�" - "'""; '� b Water table depth g SEPTIC TANK :SLType/Mfg ®,�L,! ,. Capacity _ No. Compartments i PKG. TREATMENT PLT. Type/Mfg' X -,-'Capacity _'t; Method of Disposal F SEWAGE SYSTEM—7Distance�T6 nearest: we �j' 'yFoundation" F Property-Lire S40P,A. DESTRUCTIQN LEACHING,LINE No. & Length� of lines _', \� t Total length/size FILTER BED '"" Distto newest; Weil ar' Foundation Property Line anc -� _ SEEPAGEI PITS -Depth ` }I Size`_ }" Number-: = =z u ,A� SUMPS 'Distance} to nearest: Well Foundation i:. Property Line DISPOSAL PONDS I hereby certify that,I have'prepaired•'this,application and that the work will be done in accordance with,,San Joaquin countyi ordinances, state laws;'and,rules and,.regulations of the San,Joaquin,Local Hea'•1`th District, r : Homeowner or Iicensed ,agent's s'ignature-c•ertifies`the f6ll-Ewing: "I ceetify"`t'hat in the performance ofLthe work. for which this wr permit is issued, I shal-l_not.employ Any.,person in such manner-as to becbk subj.ect-to-workman s.compensatiom laws of California." Contractor's hiring or sub-contrae'ti'ng signature certifies the following: "I certify that in the performance of the work for which this' .ermit. is issued, I shall employ persons subject to workman's compensation laws of California." *� The,applicant must ca fo,r yl re wired inspections. Complete drawing on reverse sid . Signed X_ Title:. - Date: i T- F D TMENT-l1SE ONLY Application Accepted by / Rrea Q r Stk 466-6781 y Additional Comments: �] Lodi 359-3621 Pit or Grout Inspection by 4Date Manteca 823-7104 , Final Inspection by �� .' t Date L Tracy 835-6385 Applicant - Return all copies to: Environwe a Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. FEE' "`BASE"` "AMOUNT DUE--- - -.---AMOUNT,REM.ITT"EO,.._ ' RECEIVED.SY., , . __pAT.E PERMIT-NO... .. INFD - 9 EH 13-24 REV. 10/82 + _ m 10/82 500 i '^ 14-26