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APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUE() 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 Rule and�Regulati-ones of the San Joaquin Local Health District. Job Address �,,y OFE/� fo,y S�Csa�c Subdivision Name coo Owner's Name p Address 7219S Phone Contractor's Name License No. ,� 1� S.`Co Phonexk/Ly TYPE OF WELL/PUMP.WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �D SEWER LINES /J -{- DISPOSAL FLD.y D '-f PROP.. LINE FOUNDATION Q AGRICULTURE WELL,< OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. it 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1/2 M Domestic/PrivateGravel Pack ❑ Tracy » Dia. of Well Casing �] Public �Ot her Delta Type of Casing oe V"4 LJ Irrigation Approx. ❑ Eastern Depth ti t P hSpecifications Cathodic Protection❑ Depth of Grout Seal �I( ❑ GeophysicalType of Grout14 FJ Other Surface Seal Installed by �NQLc)dyIra rn Repair Work Done ❑ . Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') — Depth Filler Material (Below 50') CA 0 TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted-if public sewer is Z available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size ?OR1 Character of soil to a depth of 3 feet: Water table depth 3 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG..TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM No Distance to nearest: Well Foundation Property Line. y� DESTRUCTION (�,Z,`� LEACHING LINE F-1 No. & Length of lines Total length/size "'V FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS 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 perso in such manner as to become subject to workman compensation laws of California." Contractor's hiring or sub-contracting Signa re certifies the following: "I cert ify that in the performance of the work for which this permit is issued, I shall loy pe o subject to workman's compensation laws of California." The applica t call f al equir spe Complete drawing on reve se side. Signed Title: Date: J J F DE RTMENT USE NLY Application Accepted by rea A Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection by Date l 3 0 :2?' ❑ Manteca 823-7104 Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to: Enviro tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BR$E AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10l82 500 14-26