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APPLICATION FOR PERMIT SAN JOAQUIN LDCAL HEALTH DISTRICT .p 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED a- Y 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 / 7 ri A, f 9 - - Subdivision Name Owner's Name Address 100 Phone Contractor's Nam ' License No. �'1�sZZCD Phone �lo? TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT E] 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 t'4+ ❑Open Bottom ❑Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing ❑ Public [j Other ❑Delta Type of Casing U Irrigation _!Approx. „ ❑Eastern Specifications E]Cathodic Protection — -. Depth -- ❑Geophysical Depth of Grout Seal U Other \ Type of Grout Surface Seal Installed by Repair Work Done El Type of Pump H.P. State Work Done Well Destruction ❑ -Well-Diameter, - Sealing Material (top 501) - - Depth Filler Material (Below 50') J TYPE Of SEPTIC WORK: NEN INSTALLATION [7j _REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is .J / available within 200 feet.) Installation will serve: Residence (� Commercf al Other - (. Number of living units: Number of drooms �Lot size.20 R.fJLR-ate Characterofsoil to a depth of 3 feet: Water table depth /(}Q SEPTIC TANK [j Type/Mfg ^—� Capacity No. Compartments - PKG. TREATMENT PLT. ❑ Type/Mfg i Capacity Method Of Disposal Distance to nearest:. Well Foundation Property Line LEACHING•LINE ❑ No.,& Length of lines Total length/size FILTER BED ❑ DI-stance to nearest: Well 1 Foundation Property Line �( SEEPAGE PITS Depth. ... . Size �(o Number 1 OO v SUMPS • -U � Distance to nearest: Ne11 B�f.Foundatio Property Line DISPOSAL PONDS ED I hereby certify that [`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. . Homme 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 sKall not employ any person in such manner as to become subject to workman!compen satian 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 applicnt mustall for all required inspections. Complete drawingn reverse side. ••--�� rr�� Signed X � Title. —. 0. Date: / 2 — 10— i FOR DEPARTMENT USE ONLY .ADD icati on Accepted t) � Area 0 _ �Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection- Latef� (� Manteca 823-7104_ Final Inspection by Date ��--7�� ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Mazelton'Ave., P.O. Box 2009, Stk., CA 9520I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ALAS -:17 1 EH 13-24 REV. 10/82 10/82 500 14-26 4..