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r APPLICATION FO;i PERMIT SAN JOAQLi'+ LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. 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 Regulations of the San Joaquin LOC131 Health District. Job Address P Subdivision Name Owner's Name Address 9 Art, V Phone- Contractor's Na [� t, G c_ License No. _ S 7 �/ Phone 3 4 3 I TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r,, PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 1!" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� Industrial ❑ Open Bottom F-1MantecaDia. of Well Excavation 1J Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Y f 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 N.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C�_ (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: —I-- Number of bedrooms Lot size l0 C-_ , Character of soil to a depth of 3 feet: - W, Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE No. & Length of lin - S Total length/size FILTER BED ❑ Distance to nearest: Well / Foundation � r__ Property Line SEEPAGE PITS Depth _ Size 3 11 Number �a SUMPS ❑ Distance to nearest: Well ` Foundations 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 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 sh 11 employ persons subject to workman's compensation laws of California." The applicant mu c fo a l equired inspections. Complete drawing on reverse side. Signed X Title: jo LJ Date: FOR DEPARTMENT USE ONLY Application Accepted by a Area ❑ Stk 466-6781 Additional Comments: T Lodi 369-3621 Pit or Grout Inspectio4b ) Date Manteca B23-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copie nvir. ment 1 ealth Permit/Services 160 E. azelton Ave., P.O. Bnx 2009, Stk., CA 95201 FEEO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEkPERMIT NO. "M INF 1 I�iS EH 13-24 REV. 10/82 10/82 500 14-26