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APPLICATION FOR PERMIT Ste` SAN JOAQGiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 GATE ISSUED J13 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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 Regulatof he San Joaquin Loca Hyl,th District. Job Address < {j d� io s 0� Su division Name Owner's Nam , Address Phone Contractor's Na ' p COLicense No. Z Phone �� �UX], TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑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 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 permittedithiif nublicfseter is avkInstallation will serve: Residence _ l Commercial �Other a Number of living units: Number of drooms � Lot size Character of soil to a pth of 3 feet: ` �7�'� —— ater table depth SEPTIC TANK IBJ ype/Mfg 11 Capacity G o. Compartments PKG. TREATMENT PLT. F-1 Type/Mfg � Capacity Method of Disposa] SEWAGE SYSTEM ❑ Distance to nearest: Well — Foundation O_ Property Line '+T DESTRUCTION Total length/size LEACHING LINE ❑ No. & Length of lines � FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSDepth Size Number ❑ Distance to nearest: Well Foundation Property Line SUMPS L i 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 to become subject to workman permit is issued, I shall not employ any person in such manner as 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 f al required inspections. Complete drawing on�re e side. Date: Signed X Title: pgw/�� OR DEPART NT USE ONLY Area �_ ❑ Stk 466-6781 Application Accepted by C Lodi 369-3621 Additional Comments: ❑ Manteca 823-7104 Pit or Grout Inspection Date Final Inspection by Date , ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 160 E"aeltn Ave., P.O. Box 2009, Stk., CA 95201 PERMIT N0. FEE BASE ;Z��UE AMOUNT REMITTED RECEIVED BY DATE [�//�� INFO 1=7 �3� 4V 10/82 500 EH 13-24 REV. 10/82 14-26