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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON RUE., STOCKTON, CA PERMIT NO. S 3 I DS Telephone (209) 466-6781 : GATE ISSUED -z-- 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 County Ordinance No. 549 for sewage_ or No. 1862 for well/pump .and the Rules and Regulations of the.San Joaquin Local Health District. Job Address �� 3r7%N/U/�_ Subdivision Name Owner's Name _� �� t Lt}� -_ Address Phone Contractor's Name _A ru�LL�ie License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL I REPLACEMENT DESTRUCTION W PUMP INSTALLATION L] SYSTEM REPAIR OTHER U 1 DISTANCE TO NEAREST: SEPTIC TANK rT DISPOSAL FLO. PROP. LINE SEWER LINES �� F� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v 17 Industrial U Open Bottom f7 Manteca Dia. of Well Excavation _ jJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other ] Delta Type of Casing L Irrigation Approx. ❑ Eastern Specifications Cathodic ProtectionDepth A LL. Depth of Grout Seal Geophysical a L, Y Type of Grout Lf Other, Surface Seal Installed by C Repadr_Work-Done Type.of Pump H.P. State Work Done r j Well Destruction ❑ . Well Diameter - Sealing Material (top 50') / Depth 'P w Filler Material (Below 50') j .i TYPE OF SEPTIC WORK: NEW INSTALLATION Fj REPAIR/ADDITION U .(No septic tank or seepage pit-permitted.if public sewer is c _ - available within 200 feet.) Installation wi-ll serve: Residence Commercial Other Number of living units: Number of bedrooms - Lot size. Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK .. gj Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity AWM69L Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation [ Property Eine y DESTRUCTION - LEACHING LINE [J No. & Length of lines Total length/size FILTER BED Distance to nearest: Well // rj i�r Foundation Property Line SEEPAGE PITS ❑ Depth Size Number > SUMPS L1 Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ 41 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. k ' 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, l 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 or all required inspections. Complete drawing on reverse side. Signed, X _Title: -D-ate: t FOR DEPARTMENT USE ONLY -Area Stk 466-6781 ❑ Application Accepted by Additional Comments: + Ej Lodi 369-3621 Pit or Grout Inspection b Date Lel Manteca 823-7104 Final Inspection by _ Date"Z ❑ Tracy 835-6385 Applicant - Return all copi to: Environmental Health Permit/Services'AOI E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED , RECEIVED BY DATE PERMIT NO. INFO 93- 105 EH 13-24 REV. 10/82 10182k-500 14-2b A-. }