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ex, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 '�A ]� DATE ISSUED 0 O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �� Application is hereby made to three San Joaquin,local Health District 'for a p�ermiiit to construct and/or install the work her described. This application is made in compliance with San Joaquin County Ordingnce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Addre99F I Subdivision Name Owner's Name ��L Address G *% one Contractor's Name FLdyJ J04-D License No. 42's,.2.7(, Phone - LA TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J -� PUMP"•1NSTALLATION 0=- SYSTEM REPAIR _OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 0 _ 'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TY?E OF 'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑Open Bottom ❑ Manteca Dia, of Well Excavation ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public [Other ❑.Delta Type of Casing V Irrigation Approx. [].Eastern Specifications ❑Cathodic Protection Depth: Depth of Grout Seal � ( Geophysical F� Type of Grout 1 0ther Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. ', State Work Done I + Well Destruction ❑ Well Diameter • " Seali4 Material (top 50') ,Depth Filler Material (Below 50') REPAIR/ADDITION TYPE OF SEPTIC:WORK: NEW INSTALLATION.-, (No septic tank or seepage pit 200 feet.) permitted if public sewer is available within Installation will serve: Residence _ Commercial - Other Number of living units: _L Number of.bedrooms Lot size 7 O� s j Water table depth �} Character of soil to depth of 3 feet: �Q AJP l� SEPTIC TANK' E Type/Mfg .— �9�- Capacity J��-aQ No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well. Foundation /S Property Line ' 'DESTRUCTION '. LEACHING LINE No. & Length of lines 3 �( Well ...---- Total length/size X Z { FILTER BED ❑ Distance to nearest: Well i6e ' Foundation Property Line -��--- -'r"" Size Number SEEPAGE'PITS Depth o2 SUMPS # Distance to nearest: Well g'(�' Foundation 4f Property Line i _J 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 performance of the work far which this permit is issued, 1 shall not employ any person in such manner as tobecomesubject 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 i spections. Complete drawing on reverse side. Signed X Title: Date: F R�OEPARTMENT USE ONLY Application Accepted by + Area —4;91❑ LodStk 466-6781 Additional -Comments: i Lodi 369-3621 Pit or Grout Inspection y Date ❑ Manteca 623-7104 r Final Inspection by Oates#1E. ❑ Tracy 835-6385 Applicant - Return all copies to: . Envi o ental Health Permit/Services 1azelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED "--RECEIVED BY DATE .p, PERGM]IT N0. INFO o� 3o 3 D 3— I3q - _ — 10/82 500 EH 13-24 REV.10/82 14-26