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R APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 007--&575��- 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ? Telephone (209) 466-6781 / / y 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 workherein 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 Subdivision Name Owner's Name Address Phone Contractor's Name License No. Phone '-'?'� 4 1 TYPE OF WE WORK: NEW WELL L WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER (� . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �/DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V 17 Industrial ❑Open Bottom � Manteca Dia, of Well Excavation 17 Domestic/Private Gravel Pack Tracy Dia, of Well Casing f 0 Public C1 Other Delta L IrrigationType of Casing , I Approx. Eastern Cathodic Protection Depth Specifications l7 Geophysical Depth of Grout Seal L[Other Type of Grout Surface Seal Installed by Repair Work Done ] Type of Pump H.P. State Work Done Well Destruction L Well Diameter Sealing Material (top 501) Depth Filler Material (Below 501) . Od TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION L (No septic tank or seepage pit permitted if public-sewer is ..S) Installation will serve: Residence — Commercial _ Other p / available within 200 feet.) Number of living units: Number of bedrooms ,�_�L+ot size �. Character of soil to a depth of 3 feet: c� 71wat er table depth lQ SEPTIC TANK ] Type/Mfg �l rv-r t3'Ir#_ Capa ity /WD No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal Distance to nearest: Wellj:' Foundation -Z0 �.. Property Line LEACHING LINE A No. & Length of lines 2 O t Total length/size aO FILTER BED 0 Distance to nearest: Well Ott � Foundation -30 Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS LI Distance to nearest: Well 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. 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 must call for all r ired in cti s. Complete dra 'ng on.,reverse si Signed X - Title: t Date: D RTMENT USE ONLY Application Accepted by Area Q Stk 466-6781 f Additional Comments: ❑ ' Lodi 369-3621 i Pit,or Grout Inspection by Date Manteca 823-7104 Final Inspection bytii. Date "� Tracy 835-6385• Applicant - Return all copies to: Environm ntal 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 3�2 EH 13-24 REV. 10/82 14-26 10/82 500 7