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i' j r APPLICATION FOR PERMIT s SAN JOAQM! LOCAL HEALTH DISTRICT n 1601 E. HAZELTON AVE.1 STOCKTON, CA PERMIT NO. Telephone (209) 456-6781 w PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (Complete in Triplicate) Appiicatioh is hereby made-to the San Joaquin Local Health District for a permit to construct and/or install the work'herein v described. This application is made in compliance with San Joaquin County Ordinance No, 544 for sewage or No: 1862 for well/pump and the Rules and Regulation of the San Joaquin Local Health D' ho ict. „ Job Address )� ea" ub' vision Name _ - A, %_ z J O Owner's Name i Address." Phone Contractor's Name k License No. Phone ( r TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT-❑ _ w DESTRUCTION ❑ ar PUMP INSTALLATION ❑ SYSTEM!REPAIR-10 ' LJ � OTHER DISTANCE- TO NEAREST.: SEPTIC TANK tI _ _ SEWER LINES DISPOSAL FL•D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 71 Industrial U Open Bottom [] Manteca Domestic/Private ' Dia. of Well Excavation ' �. ..•. U ❑ Gravel Pack ❑ Tracy Dia, of-We11.Cas-i ng , I—] Public' ❑ Other ❑ Delta T Irrigation Type of Casing ation f'3 { Lj 9 Approx. Eastern ❑ I ,.' .` r�.. iioCathodic Protection Depth DeptSpecifications of Grout Seal Geophysical .' ��' Y Type of Grout Other : I f - f Surface Seal Installed by Repair Work Done ❑ Type of Pump € H.P. State Work—Done___ . Well Destruction ❑ Well Diameter Sealing Material (top 50') it +yi Depth Filler Material -(.Be1oWL50') + TYPE OFiSEPTIC WORK: NEW INSTALLATION>< REPAIR/ADDITION 1J''(Noseptic tank or seepage pit permitted if public sewer}is ' � `�, `� � <J. '� a available within 200 feet.)' . Installation will serve: Residence � Commercial Other" --. �Kx Number of living units: —1-2-Number of bedrooms+ _ Lat size .-4eA4�" r .Character of soil ti o a' depth of 3 feet:. •. Water table depth _ /,76 ' SEPTIC TANKType/Mfg ��,(�� i�s�lS� Capacity _# ,�42 ;No. Compartments PKG. TREATMENT-PLT. ❑ Type/Mfg I r t Capacity Method of Disposal SEWAGE-',SYSTEM ��--1 Distance'to near"est: Well I Foundation ." �Property Line LEACHING LINE No. & Length'of lines .— (�@ Totallength/size . FILTER BED ❑ Oistance to neare.st: Well ,Qj r Foundation „ �. Property Lineup SEEPAGE PITS Depth;��"�� Sizee� I 'Number;; SUMPS L Dis ante to nearest: Well Q r Foundation _ 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. w. 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 it--ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit .issued, I shall employ Znsfeet to work 6"s compensation laws of California." The appl st all for ll re on Compl on reverse side. a/� Signe X Title: Date: FOR DE ARTMENT USE ONLY Application Accepted byX9 Area _ [] Stk 466-6781 ot Additional Comments: Lodi 364-3621 Pit or Grout Inspection ` 4 to (} ( Li Manteca 823-7104 Final Inspection by to ] Tracy 835-6385 r Applicant - Return all copi s to: En ironmental Health Permit/Services 1601 zelton Ave., P.O. Box 2009, Stk., CA `95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVEDBYDATE PfRMIT'NO, 1 INFO lop 0 EH 13=24°-.REV.=1-0/82 .10/.82.-.,500 14-26