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i APPLICATION FOR'PERMIT w SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 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 lade in compliance with San Joaquin Count Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations oft a San Joaquin Local Health District. y g /pump a Job Address Subdivision Name ! Owner's Name _Address Phone rj' Contractor's Nam License No. _ ,t +} PhoneupCJ4 TYPE OF WELL/PUMP WORK. NE141 WELL ❑ WELL.,REPLACEMENT ❑M____OEST=RUC.TI.ON -F=- r„•��,.,. . .. �� >„,�_,... 11 PUMP INSTALLATION ❑ SYSTEM REPAIR i ❑ DISTANCE TO NEAREST: SEPTIC TANK ;� ❑ OTHER 9 F n SEWER LINES DISPOSAL FLO. V l L PROP. LINE FOUNDATION I AGRICULTURE WALL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL PROBLEM AREA J/<' CONSTRUCTION SPECIFICATIONS Industrial ❑ Open1 ❑Bottom Manteca Dia. of Well Excavation L-] Domestic/Private ❑Gravel Pack ❑ Tracy , Dia, of Well Casing 1-1PublicOther :. F111Del tam ) �j Irrigation Type of Casing ; ;tr, Approx. Eastern ❑ Cathodic Protection Depth Specifications 17 Geophysical ~'y s J aY Depth of Grout Seal LJ Other x'w+.'' , + '�' Tyke of Grout i Su''rfacp.-Seal-..Instal.led..hy--,,.--__.,.,_ Repair Work DaneType of Pump'+, _�'`'� H,P, State fork hone + Well Destruction Well Diameter U Sealing Material (top 50') S Depth 1 � .,FiaTler Material (Below 50.) f TYPE OF SEPTIC WORK: NEW INSTALLAT{ION ❑ REPAIR/ADDIT`ION C&T-T—No septic Tank or seepage pit,.pernlitted if public sewer: i Installation will serve� ;Residence _ available within 200 feet.)_ i commercial Other 5 - i Number of living units: Number of bedrooms ' p Lot size Character of soil to a depth of 3!feet: """-""'"-� SEPTIC TANK ; , „� Water table depth T jj 1 ❑ Type/Mfg i �` ;�, f Capacity No. Campartments PKG. TREATMENT PLT. ❑ Type/Mfg 1 •� f� Capacity Mgthod. of DisposaA_ Distance to nearest: Well `Foundation ” _ _.r... t Property,Line LEACHING LINE No. & Length of Tines 4 Totl Tength/size ` FILTER BED ❑ Distanceltiv nearest: Well Foundation i Property Line,* ; SEEPAGE PITS � th P Size e _ � Humber•.:-.•„ ,..�.-•.--... ` .. '"' _ F' �� SUMPS ❑ Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS 61 1� 0 1 _,41 , �f i; :s . i y I hereby certify that I have prepared this application and that the workwill be done in accordance with San Joaquin county i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, v� x Home owner or licensed agent's signature certifies the following: "I certify that in the permit is issued, I shall not employ any person in such manner as to become subject to workman compensation�lawsrkaof.-California." Contractor's hiring o -contracting signatu certifies the following: "I certify that in the performance of the work for which'; this permit is issshall employ p s bject to workman's compensation laws of California_" z The appli n 1 or all r �mpl everse side. Title: 101 tl1QC`u��- -_ Date: F R DEPA ENT USE ONLY Application Accep e y Area Additional Comments: 1 ❑ Lodi 369-3621 Pit or Grout Inspection b Date_-Y Manteca 823-7104 Final Inspection by Date , -�'3 Tracy 835-6385 Applicant - Return all copie t Erivironm 1 alth EPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 r1NFO ASE AMOUNT DUE1 AMOUNT REMITTED RECEIVED BYDATE PERMIT N0, EH 13-24 REV, 10/82 a 14-26 10182 500