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1 � � APPLICATION FOR PERM h i SAN JOA4UiN LOCAL HE.ALTti DISTRICT 'f 1501 E, HAZELTON AVE., STOCKTON, CA PERMIT NO, Telephone (209) 466-6781 DATE ISSUED 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 Regulatibns of the San Joaquin LocalHealthDistrict. Job Address 3 Subdivision Name F Owner's Name Address 2 ., Phem Contractor's Name7 -- - �,� License No. 2�r7 Phone I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ii , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE FOUNDATION ON AGRICULTURE WELL ``• OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS I� ❑J Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel-l:.Excavation ❑ Domestic/Private ❑ ❑ y _*a.1 Gravel Pack-� Trac Dia. of-+Wel l Casing.; ❑ Public- hDelta Other } ea -g ❑ ❑ Type of Casing G Irrigation ' Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth r a Depth of Grout Seal ❑Geophysical s'"""` -Type of Grout ❑ Other h �� Surface Seal Installed by +' Repair Work-Done.❑ Typeof Pump H.P. State Work Done Well Destruction ❑ WelI-Diameter Sealing Material (top 50') _ s Depth Filler Material (Below 50') TYPE OF SEPTIC WORK; NEW, INSTALLATION L- 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: 1 Number of bedrooms �- Lot size (p C� 3 / Character of soil tto,!a depth of 3 feet: Water table depth a p SEPTIC TANK I�f Type/ Mf `--r 6apaci•ty. ,f —No, Gompartments_. ,. h PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well $Foundation _[17_�r Property Line .E DESTRUCTION `I t LEACHING LINE No. & Length of lines �- 0 Total length/size II FILTER BED ❑ Distance to nearest: WellU 'Foundation d Property Line rte' II � �r ! SEEPAGE PITS Depth size �� Number SUMPS Distance to nearest: Well 1,0,10 Jq-foundation lT- 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 as to become subject to workman compensation laws of California. permit is issued, I shall not employ any person in such manner " .r 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 50fcall for all r red inspections. Complete drawing on reverse side. Signed X Title: Date: I, F EPARTMENT USE ONLY E' Application Accepted by Area �. ❑ Stk 466-6781 Additional Comments: Lodi 369-3621 Pit yr Grout Inspection by Date Manteca 823-7104 Final Inspection by Date. —q ❑ Tracy 835-63851 I Applicant - Return all copies t Environmental Healt ermit/services 160 E. azeltorS AveP.O. Box 2009, Stk., CA 95201 �I FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. �I INFO J 1LJA 1 EH 13-24 REV. 10/82 10/82 500 14-26