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APPLICATION FOR PER?iiTcall �. SAN JOAQUiN LOCAL HEALTH 'uISTR 1601 E. HAZELTON AVE,, STOCKTON PERMIT NO. 3 -C:Z Telephone {209) 466-1111 �'" DATE ISSUED �3 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is herebymade to the San_ Joaquin Local Health District for a perzmiti �� Mlt and/or install the work herein r described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for''well/pump Or, and,.the Rules and Regulations.of the San Joaquin Local Health District. Job Address I II ; m " Subdivision Name 1� Owner's Name Address Q1 h �s.� Phone P2'] Contractor's Name License No. Phone Q TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS LA INTENDED USE -TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS w_ y- -- �..+ , J Industrial U Open'Bottom Manteca Dia. of Well Excavation j Domestic/Private Gravel Pack Tracy Dia. of Well Casing Public Other: Delta Type of Casing { Li Irrigation Approx. [] Eastern Specifications ❑ Cathodic Protection Depth t Depth of Grout Seal EJ Geophysical Type of Grout N k f Otherfk UAAAar Surface Seal Installed by Repair Work Done Type of Pump 2 H.P. f State Work Done Well Destruction U Well Diameter's Sealing Material (top 501) — Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION E] (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: IINumber of bedrooms Lot size Character of soil to a depth off3 feet: Water table depth E Ca acit No. Compartments SEPTIC TANK Type/Mfg p y I PKG. TREATMENT PLT. � Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distanceto nearest: Well Foundation. Property Line DESTRUCTION LEACHING LINE No. & L&Igth of lines Total length/size j FILTER BED Distanceto nearest: Well Foundation Property Line jr -- SEEPAGE PITS Depth ' s Size Number SUMPS L1 Distancelto nearest: Well Foundation Property Line 1 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 ca2r all requi-red inspections. Complete win on reverse side. �3 f Signed X Title: —t_ Date: i4 R DEPARTMENT USE ONLY � � Stk 466-6781 ;� Application Accepted by Area _� II Additional Comments: [] Lodi 369-3621 ` Pit or Grout Inspection byf Date Manteca 823-7104 Final Inspection by Date 1 2-0-4-:5 L7 Tracy 835-6385 Applicant - Return all copies o: Envirormental Health Permit/Services 1601 E. Hazelton Ave., P.O. box 2609, Stk., CA 95201 4 FEE BASE AMOUNT 1DUE AMOUNT REMITTED RECEIVED BY E/DATE PERMIT NO. INFO 10182 '500 EH 13-24 REV. 10182 14-26 i