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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. _4 OH 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 Regulati ns of the San Joaquin Local Health District. Job Address e//( .� _ Subdivision Name Owner's Name „ +yr � Address Phone Contractor's Name ` � - �jC Z4c r-�, License No. " Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Sear ❑Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done [] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ` n 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 of living units: _/_ Number of b drooms Lot size f Character of soil to a depth of 3 feet: Water table depth V(/n SEPTIC TANK ❑ Type/Mfg 17Capacity No. Compartments , PKG: TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION r* LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation e( Property Linc .,SEEPAGE PITS ❑ Depth 3 — Size X L Number SUMPS Distance to nearest: Well Foundatibnf(,�► 'Property Line Fj J DISPOSAL PONDS ❑ -`f� 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 ust call r 1 required inspections. Complete drawierse side, , Signed X Title: ng n vDate: OR DEPARTMENT USE ON Appl 'c tion Accepted by Area __2,__ ED Stk 466-6781 1 Additional Comments: X Lodi 369-3621 Pit or Grout Inspection by Date L:1 Manteca 823-7104 Final Inspection by r Date b, ❑ Tracy 835-6385 1 �v Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.,, INFO EH 13-24 REV.. 10/82 10/82 500 14-26