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APPLICATION FOR PERMI SAN JOAQUiN LOCAL HEALTH STRICT )� � I 933 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. p ^tJ Telephone (209) 466-6781 TO � � �AQUIN LOCAL DATE ISSUED LP, PERMIT EXPIRES 1 YEAR FROM DATE ISN LT}� DISTRICT (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 Joaqu n Local Health District. Job Address �Q� � �. f�1V�ri �, . Subdivision Name Owner's Name T { Address SA Py%"e Phone Contractor's Name.T Syy' V License No. 70/O Phone p Zit►7 TYPE OF WELL/PUMP WORK: NEWIWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F—Jindustrial U Open#Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑0ther ❑ Delta I Type of Casing ❑j Irrigation Approx. ❑ Eastern F-1CathodicProtection Depth Specifications Depth of Grout Seal 17 Geophysical Type of Grout ❑Other Surface seal Installed by k Repair Work Done [Z Type of Pump j - H.P. State Work Done Well Destruction ❑ Well DiameterSealing Material (top 50') Depth Filler Material (Below 50') CA 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: !Number of bedrooms Lot size c Character of soil to a depth of ;3 feet: Water table depth SEPTIC TANK E] Type/Mfg F Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg' Capacity Method of Disposal SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line DESTRUCTION I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance'to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth [ Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I - 2 1 hereby certify that I have prepaIred this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules Land 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 sha1T 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 applican lust call 1 required inspections. Complete drawing on reverse side. Rei Signed X [ Title: Date: EPARTMENT USE ONLY Application Accepted by • Area D ❑ Stk. 466-6781 Additional Comments•:--i ( ❑ Lodi 369-3621 Pit or Grout Inspection byl Date r ¢¢ ? ;Manteca 823-7104 Final Inspection by CDate7—fog P� W/ L7 Tracy 835-6385 Applicant - Return all copies to: ,0 Environme Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEF BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO , ` �[ ��78 `-1' ] 1 EH 13-24 REV. 10/8210/82 10/82 500 14-26 C/ iv