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APPLICATION FOR,PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. .3 72L Telephone (209) 466-6781 t�b Cj� DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i - F E (Complete in Triplicate) r! I Application is hereby made to the San Joaquin Local Health District for a permit to construct-and/or install the work herein described. This applicatior is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for'well/pump 1 and the Rules and Regulations of the,San Joaquin Local Health District. i Job Address . a?✓f Subdivision Name Owner's Name Address 2_� _ Gfl,/.�� - Phone Contractor's Names-�+�.�r�� /:�,—,49erp,--,J icense No. Phone TYPE OF WELL/PUWORK" NEW WELL ❑ WELL REPLACEMENT [] DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ w { u DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ? FOUNDATION.' AGRICULTURE WELL OTHER WELL PITS/SUMPS d> INTENDED USE TYPE OF WELL PROBLEM AREA CDNSTRUCTION SPECIFICATIONS Industrial f_ Open Bottom Manteca Dia, of Well Excavation U Domestic/Privatey 3 Gravel Pack Trac Dia. of Well Casing ❑ Public « ❑Other ❑ Delta Type of Casing V Irrigation Approx. Eastern Depth Specifications ❑Cathodic�F�rotection Depth of Grout Seal 1-1Geophy5i-cal � �• Type of Grout U Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material (top 50') _ !� F Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: ' Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ *Type/Mfg Capacity No.'Compartments \11 r i PKG. TREATMENT PLT_, Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation. Property-Line DESTRUC.TI6N LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 { SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS s,. I 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'sisignature 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 's issued, I shall employ persons subject to workman's compensation laws of California." ? The appl" a must call f r all required inspections. Complete drawing on reverse side.` Signed X Q p� Title: Date: I ENT U NLY nn "J Applica ion Accepted y Area V 5tk 466-6781 U ❑ <, Additional Comments: Lodi 369-3621 Pit or Grout Inspection,by ]ate ❑ Manteca 823-7104 Tracy 835-6385 Final Inspection by /%/� :.'-a Date L Applicant - Return all copies to: . Environmental Health / rmit/S rvices 1601 F. Hazel on Ave., P.O. Box 2009, Stk-, CA 95201 FEE BASE AMOUNTt DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. (� INFO 0 14911 10/92 500 EH 13-24 REV. 10/82 r . r 14-.26