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APPLICATION FOR PERMIT SAN JOAQ1ULN LOCAL HEALTH DISTRICT = 1 r 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 aj4 Regula-t]ions f the San Joaquin Local Health District. Job Address ( Subdivision Name R Owner's Name Q tl Address Phone Contractor's Name LEE \Nt AL'OkKk ._ License No, 41 Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER U ! r 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 IJ Industrial U Open Bottom F Manteca Dia. of Well Excavation _ F—I Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ' Public Other y E Delta - Type of Casing FIIrrigation Approx. D Eastern ❑ Cathodic Protection Depth Specifications --. _ Depth of Grout Seal Geophysical - "Type.-of_Grout Other Surface Seal Installed by-. A Repair,Work Done D Type of Pump- - H.P. State Work Done „� V Well Destruction U Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (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 TANKType/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ? Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM o 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 CI Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 performantA of the work for which-this perm'"t 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 s permit is iss ed, I sh 1 employ persons subject to workman's compensation laws of California," The app t u t al f r 11 ui e inspections. Comp awing o reverse de. Sig Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by "'" Area � ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date LJ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all caes Envi p ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIHIBY MITDATE PERNO. EH 13-24 REV. 10/82 L r / /1'wr+`�' 7 O"b 1r •� '� w 1 I/80 2 500 14-26 !I\,1`" �J rvY. [ ✓ :f. Ar TV 6vlJ