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APPLICATION FOR PERMIT ME r / SAN JOAQL:N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CARF1II N0 ��—y � Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE 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 Regulatlon,5 �of the�San Joaquin Lo al Health District, Job AddreS H=��•"'amu-at-(I�LIL : Subdivision Name Owner's Name Address Phone Contractor's m ' 7 License No. Phone Phoneb TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT E] DESTRUCTION EJ PUMP INSTALLATION SYSTEM REPAIR OTHER O V" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 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 L_I Domestic/Private F]Gravel Pack ❑Tracy Dia. of Well Casing Public F—i Other ❑ Delta T irrigation pee of Casing Li 9 Approx. �Eastern Specifications Cathodic Protection Depth —_. Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION — REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is (J� & Installation will serve: Residence _*'� Commercial Otheravailable within 200 feet.) J'f Number of living units: Number of bedrooms _ Lot size Character of soilto a epth of 3 feet: Water table depth /;20 SEPTIC TANK Type/Mfg Ctite Capacity _ 1_�24Q_ No. Compartments PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well �r0 Foundation i Q Property Line DESTRUCTION rt LEACHING LINE U Mo. 8 Length of lines — L CJ Total length/size X o[ FILTER BED E] Distance to nearest: Well , <Z:iQ X Foundation /fl , Property Vne ,f SEEPAGE PITS Depth AcS Size Numbers, y - SUMPS U Distance to nearest: 1 " Fo ndat ion J 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 shall not employ any person in such manner as to become subject to workman4 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 ust call r 1 required inspections. Complete drawing o ,r�y/�erse side. n Signed X Title: �! Date OR DEPARTMENT USE ONLY A pl' ation Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection b Date ,E nteca 823-7104 Final Inspection by Da ❑ Tracy 835-6385 —�� *1z.lt1�'Ave.,Applicant - Return all copies o: Envirc mental Health Permit/Services 1601 E. P.O. Box 2009, 5t1k., CA 95201 FEE I BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY / DATE p PERMIT NO. INFO 4 � � IO,o�I� 3-4� EH 13-24 REV. 10/82 10/82 500 14-26