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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT yy�� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NOQ Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5-9 (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 % +,�Name s <:Z 57SAli ' Owner's Name 1%✓r M.ltP, Address .2*,1 r € Phone 5107 JG Contractor's Name 4S"Li ked fact icense No. Ug!fAt Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ �] DISTANCE TO NEAREST: SEPTIC TANK 'xp f SEWER LINES DISPOSAL FLD. 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 /�tr Domestic/Private X Gravel Pack ❑ Tracy Dia. of Well Casing 6 Public ❑Other E] Delta Type of Casing T`/�CG L jJ Irrigation Approx. ❑ Eastern Depth Specifications FI Cathodic Protection — _ Geophysical J/��/ Depth of Grout Seal 5j Q 17 [J Other /� 2-7 Type of Grout ('e^ r,dt Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done r„ 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 available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number off living units: Numberofbedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK" Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal 1� SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line 1 DESTRUCTION ❑ LEACHING LINE Lj No, & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 workman§ 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 mus all `f � all eq ed Lions. Complete drawing or reverse side. Signed K Title: Date: F R A _000— RTM T USE 0 SLY Application cepted by Area 0 ells^tk 466-6781 Additional Comments: Lodi 369-3621 --PI-C--or Grout Inspection by Date Manteca 823-7104 Final Inspection by Date lJ—Sof Tracy 835-6385 Applicant - Return all copies to: En ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO wt 3- -- Awl, EH 13-24 REV. 10/82 10/82 500 I4-26