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APPLICATION FOR PERMIT SAN JO.AQI !N LOCAL EALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE 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. 544 for sewage or No. 1862 for.well/pump and the Rules and Regulations of e San Joan, in Local Health District. / Job Address ! Subdivision Name L rd i Owner's Name A-es, Phone Contractor's Name +� �L nse No. %% <L-6 Phone r,/� /3 '7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR �I OTHER DISTANCE TO NEAREST: SEPTIC TANK N c�, SEWER LINES A} DISPOSAL FLO. PROP. LINE FOUNDATION --%, AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial EP-bren Bottom ❑ Manteca Dia. of Well Excavation mestic/Private L..E� ❑ Gravel Pack { Tracy Dia, of Well Casing ❑ Public ❑ Other ❑ Delta irrigation Type of Casing LJ g Approx. ❑ Eastern ❑Cathodic Protection l Depth Specifications ❑Geophysical Depth of Grout Seal , Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump- Cs H.P, 7— State Work Done Well Destruction'❑ Well Diameter Sealing Material (top 50') Depth d Filler Material (Below 50') �Ir•layl 1 1 1 i ill till�1• - - 1 TYPE OF SEPT[C. WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ_ (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: Number of bedrooms Lot size _ e Character of'soil to a depth of 3 feet: Water table depth 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number d SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C1 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 worts for which this permit is issued, I shall employ persons subject to workman's compensation laws of California." The applicant must call fpr all required inspections. Complete drawing on reverse side. Signed X 40CIZ c Title: Date: /A p F ARTMENT USE ONLY Application Accepted by Area 2_( ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit oGrout nspection by Date Manteca 823-7104 Final Inspection by Date ',� (� Tracy 835-6385 Applicant - Return all copies to: EnvironmentaY Health Permit/Services 1661 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 M FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO 36 l4S a d X258 AV 23-1s b —Ioe c v EH 13-24 REV. 10/82 ✓37 10/82 500 14-26 r