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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) 1 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 Joaquin Local Health District, Jab Address dcj3 &74 Cj A4 TQ r Subdivision Name Owner's Name lv� d Address 11.0 74c so.IJ4 75,gC Phone Contractor's Name RF AV7,Arlk OCI* License No. Y!' eir/ Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial -� . ❑ Open BottomManteca ❑ Dia. of Well Excavation � ❑ Domestic/Private ❑ Gravel PackTrac ❑ Y Dia. of Well Casing ❑ Public ❑j Other ❑ Delta Lj Irrigatiors Type of Casing Approx. Eastern ❑ Cathodic Protection DeeptthhSpecifications ❑ Geophysical ' ' Depth of Grout Seal ❑Other Type of Grout Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION JX1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence / Commercial Other available within 200 feet.) , Number of living units: / Number of bedrooms -7 Lot size / A_-yt-.r Character of soil to a depth of 3 feet: C,4�!Z AVAAr Water table depth 8' SEPTIC TANK ❑j Type/Mfg. Prt' CAr CoNc, Capacity 7a Vv No. Compartments 1, 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 JP- 90Total length/size FILTER BED ❑ Distance to nearest: Well /oo Foundation. ?A Property Line SEEPAGE PITS ❑j Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑� k 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. Signed X Title: Date: .2 R�RTMENT USE ONLY ONLY Application Accepted by Area C Stk 466-6181 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by w/ DateY E) Tracy 835-6385 Applicant - Return all copies to: Environmenta ealth Permit/Services 1601 E._ Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEO BASE AMOUNT DUE INFAMOUNT REMITTED RECEIVED BY DATE PERMIT NO. +� --37"7 EH 13-24 REV. 10/82 10/82 SOD 14-26