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wi APPLICATION FOR PERM!. SAN JOAQU N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE 155UEO -:;?-7 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 Count Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local He th� Job Address ��" - 6Q� ivision a Owner's Name {ems A, 141,116 Address Address Phone Contractor's NameA,2—��L E 4_52 License No. • !E,T or Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WFLL-,REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ T •- --- t -0. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE .J x. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation j Domestic/Private ❑Gravel Pack ry ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Depth Specifications Cathodic Protection LI] Geophysical Depth of Grout Seal U Other Type of Grout �r 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 ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is T9C�S� available within 200 feet.) %, Installation will serve: Residence Commercial � Other 7 Number of living units: a! Number of bedrooms Lot size Character of soil to a depth of 3 feet: %47y _ 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 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 tfie 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 became 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 mustcal for ll "re red inspections. Complete drawing on reverse side. p► Signed X Title: Date: -Z. a FOR DEPARTMENT USE ONLY ApplicaFtion Accepted by Area l? - ❑ Stk 466-6781. Additional Comments: ❑ Lodi - '369-3621 Pit or Grout'Inspection by Date Manteca 823-7104 Final Inspection by- Date 7� �. ❑ Tracy 1 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0 Box.2009, Stk., CA 95201 ^` s r-• FEE BASE AMOUNT DUE AMOUNT_ REMITTED RECEIVED BY DATE PERMIT NO. + INFO EH 13-24 REV. 10/82 �d�Gi Z (Jt Its d i0/82 Soo 14-26 v