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APPLICATION FOR PERMIT k SAN JOAQUiN LOCAL HEALTH-DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j 1 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 is F, 0, r' 1` Subdivision Name Owner's Name t Address ? r "i'.'' "; n7_ Phone Contractor's Name !.? 'J-'- -1 r ..n " '-License No. �- -,.,,_a,. Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L} 1 DISTANCE TO NEAREST: SEPTIC TANK ;T,a= SEWER LINES 0-'1C3 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial 0 Open Bottom, ❑Manteca Dia. of Well Excavation iJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑i Other ❑ Delta Type of Casing' Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Dane Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION. ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) t ' Installation will' serve: Residence _ Commercial VOI*'Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth 4f,_ SEPTIC TANK Type/Mfg "-' Capaciiy �r'`i� No. Compartments I PKG. TREATMENT PLT. [� Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line I DESTRUCTIONS f LEACHING LINE No. & Length of lines Total length/size t ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size -` Number SUMPS Distance to nearest: Well Foundation Property-Line 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 for which this permit is issued, I all not employ any person in such manner as to become subject to workman compensation laws of California,." Contractor's hir' or sub-contracts signature certifies the following: "I certify that in the performance of the work for which this permit i ued, I shall pers subject to workman's compensation laws of California," The applic t st-call f req d� ec ions. Complete drawing on reverse side. Title: r Date: R D TMFNT USE ONLY Application r�$� � Area Stk 466-678k { Additional Comments: X�J 1. ' f . �iL3>� f' % ❑ Lodi 369-3621 Pit or Grout Inspection by 7�' fi Date (r-�= ❑ Manteca 623-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ,f EH 13-24 REV. 10/82 10/82 50 14-26