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APPLICATION FOR PERMiT a ! SAN JOAQ6L'IN LOCAL HEALTH DiSTRiCT 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. O,2>— Telephone (20g) 466-5781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUeD DATE ISSUED FI ■(Complete in Triplicate) �Application is .hereby made to the San Joaquin Local Health District for a permit an r�� n tal the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules and Regulations of thk San Joaquin Local Health District, Job Address Q Subdivision Name r Owner's Name ,g- dress Phone — ?OJT Contractor's Name License No, 2 3 7 3 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIROTHER W L U 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 5PECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �mestic/Private Gravel Pack Trac ❑ y Dia. of Well Casin ❑ g �} ❑ Public ❑ Other ❑ Delta Li Irrigation Type of Casing ation g Approx. �Eastern Specifications Cathodic Protection Depth P -Geophysical Depth of Grout Seal - , L(Other Type of Grout Surface Seal Installed by _ Repair Work Done Qr' Type of Pump H.P. State Work Done Pre-C� /✓��. {1 Well Destruction EJ Well Diamete Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPJIC WORK: NEW INSTALLATION ❑; REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number!,of living units: Number of'bedrooms Lot size Character of soil to a depth of,3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM F1 Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number 'SUMPS ❑; Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmant 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 applic ust all f required i pert ions. CompletawY s�in on reverse side.. ! Signed X Title: Date: � i FOR DEP TMENT USE ONLY 407 Application Accepted by /�J Area'�'T p� [] Stk 466-67$1 Additional Comments: Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection by _ �Zy Date Tracy 835-6385 Applicant - Return all copies to: . Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT: DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 I0/82 500 14-26 i