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_ APPLICATION FOR.PERMIT -. SAN JOAQUIN LOCAL HEALTH DISTRICT .7 1601 E. HAZELTON AVE., STOCKTON,, CA PERMIT N0. Telephone (209) 466-6781 / DATE ISSUED Cl !J l PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health Districtafor 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 a d gulatyanfs of the San J urn Local Health District'. �c e y Jab Addressivy F1 II � � Subdivision Name L„ e e- T Owner's Name --'Address Phone x� " Contractor's Name License No. Phone p S TYPE OF WELL/PUMP-WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑' ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ . OTHER ❑ S DISTANCE TO NEAREST: SEPTIC ITANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS �- C.4 I INTENDED USE I� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation rw Domestic/Private 0 Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑Other ❑ Delta Type of Casing ❑ Irrigation IN Approx. ❑ Eastern Specifications Cathodic Protection I Depth Depth of Grout Seal ❑Geophysical Type of Grout Other a Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top,50') _ �J Depth` Filler Material (Below 50') x-i 0 V p TYPE OF SEPTIC WORK: NEW TNSTRLLATION �—T nEPAIR/ADDITION J (40 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 i Lot size Character of soil to a, Apth of 3 feet: water table depth d r SEPTIC TANK �°"Type/Mfg �..�n Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg i Capacity Method of Disposal � I ! SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION .0 LEACHING LINE No. & Length of lines Total length/size' O 4 � 1 FILTER BED ❑ ,Distance to nearest: Well PU 1&undation 0 Property Line SEEPAGE PITSi[epth �� Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, L I hereby certify that 1 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 aglnt'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 applican mus all for all r fired spec Complete d ing on reverse side. Title: Date: Signed X r Ip FO EPARTMENT USE ONLY 0 ; Stk 466-fi781 /�, f� ^ Application Accepted by Area V L _ a D �7 U ¢ ❑ Lodi 369-710 "�N(`t} Z Additional Comment's: ( Pit or Grout Inspection by Dated ❑ Manteca 823-7104 Final Inspection by Date �1�'" ❑ Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, 5tk., CA 952 D1 jf FEE BASE 1IAMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. f INFO �� /S'� �3 10/82 500 EH 13-24 REV. 10/82 14-25