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APPLICATION FOR PERMIT SAN JOAQU1N LOCAL HFALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 . DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i. (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 nd Regulations of the San Joaquinn Local District. % i • I Job Address IP Owner's Name ddress Phone Contractor's am t 6ense No. 529 2-X 4 Phone g �057 TYPE OF WELL/PUMP_WORK: NEW WELL ] WELL REPLACEMENT ❑ DESTRUCTION ❑ Il PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP, LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS `f ' f INTENDED USE TYPE OF WELL PROBLEM AREA J CONSTRUCTION SPECIFICATIONS IJ Industrial ❑ Open Bottom ❑ Manteca =' T Dia. of Wel),Excavation Domestic/Private GiavelPack T"racy" '- """" "Dia. -of-Well Gari ❑ PublicOther ,Del to U ❑ Type of Casing Lj Irrigation Ali Approx. []'Eastern Depth Specifications ❑ Cathodic Protection Depth of Grout Seal [❑Geophysical E, Type of Grout Other i Surface Seal Installed by Repair Work Done ❑ pType of Pump H.Pr 4-- -• State Work Done ate.. r... i Well Destruction ❑ Well Diameter Seal ing,,Ma.ter ia1 (top 50') _ Depth Filler Material (Below 501' „- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A�DITiONW(No sept tank orrseepage pit permitted if public sewer is r :} available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of be ooms Lotsize Q '` f[ On of soil to a depth of 3 feet: =or �• Water table depth. SEPTIC TANK Type/Mfg { Capacity' No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg ' Capacity I . Method of Disposal SEWAGE SYSTEM Distance to nearest: well Foundation Property Line t DESTRUCTION ' ❑ ti ; LEACHING LINE No. & Length of lines O �. Total length/size r., FILTER BED ❑ Distance to nearest: Well Foundation . Property Line � S SEEPAGE PITS Depth_ Size Number SUMPS ❑ Distance to negrest: well /4912 Foundation o ,010 ,.> Property Line DISPOSAL PONOS ❑� s'�f s � '' � 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 SW Joaquin Local`�06alth District. Home owner or licensed agent's signature certifies the fol,lowing:`-II•}certify that in the performance of the work for which this permit is issued, I shall not employ any person in such'mannery as to become subject to workmanis compensation laws of California." i 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 app lic t m t call for al eq fired inspections. Complete drawVg an reverse side. Signed X Title: 11.G(a Date: OR DEPARTMENT USE ONLY Ap lication Accepted by ��wl Area ;❑,� Stk 466-67$1 Additional Comments: ��TT�� Lodi 369-3621 Pit or Grout Inspection A. Environ f Date ❑ Manteca 823-7104 Final Inspection by Date L Tracy 935-6385 - copies t ental Health Permit/Services PE. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant Return all cop FEE SE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �__�A .Q g_ f r EH 13-24 REV, 10/82 Q 10/82 506 i 14-26