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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM GATE 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reg latioof the Sar Joaquin Local Health District. Job Address Subdivision Name Owner's Name Address Phone Contractor's Name �� d � [tn License No. J Phone TYPE.OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 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--- F— Excavation--- -- - Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Irrigation "Type of Casing" 71 9 Approx. ❑ Eastern Specifications 00 ❑Cathodic Protection Depth Geophysical Depth of Grout Seal Type of Grout I❑Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA] L (No septic tank or seepage pit permitted if public sewer is f available within 200 feet.) Installation will serve: Residence _✓Commercial _ Other V,44 cf ��•c Number of living units: Number of bedrooms 1 - _ Lot size S � vv Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK Type/Mfg t7 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity T Method of Disposal SEWAGE SYSTEM Distance to nearest: WellO Foundation Q � Property Line DESTRUCTION Q 7 LEACHING LINE /[� No. & Length of lines -^-f r? Total length/size FILTER BED ❑ Distance to nearest: Wellfoundation LT% Property Line _ S/— SEEPAGE PITS Z' Depth Size Number _ SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS "�— 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 for which this permit is issued, 1 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 st call foral required inspections. Complete drawing on reverse side. . Signed X / �, Title: , � _ Date: 4y 0 ARTMENT USE ONLY / Application Accepted by Area O / ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pi Lor G Inspection by Date ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copie to: Environmental He h Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 F0O BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. L1_7 3 EH 13-24 REV. 10/82 10/82 500 14-26