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APPLICATION FOP PER"::' SPN JOAQUIN LOCAL HEALTH —STRICT � ^� -9�� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J 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 a d Regulatio s of,the..San Joaquin Local Health District. Job Address Subdivision Name Owner's Name S Address A ot G— Phone Contractor's Name �C� fi _ License No. Phone —CA,4J 11 r Jyy W TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ TRUCTION E] PUMP INSTALLATION EJ SYSTEM REPAIR OTHER �� W DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v_ F-1 Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation r .} ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing V_ ❑ Public ❑ Other ❑ Delta Type of Casing Irrigation Approx. ❑ Eastern ❑ Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Donee Well Destruction ❑ Well Diameter Sealing Material (top 501) _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑1 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 bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size 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 agen ature certifies the following: "I certify that in the performance of the work for which this permit is is ed, I shall of empl y any erson in such manner as to become subject to workman compensation laws of California." Contractor's iri g or s contra ti s ature rtifies the following: "I certify that in the performance of the work for which this perm' s is ed, 11 pl y ns su ct to workman's compen ion laws of California." The appli m s call r 1 re uire e t s. Complete dra n o verse side. Signed X ft Title: Date. 6 OR D PARTM T USE ONLY Application Accepted y Area i ❑ Stk 466- 781 Additional Comments ❑ Lodi 369-3621 Pit or Grout Inspection byDate ElManteca 823-7104 Final Inspection by �. �� DatefOl 4EEel5tn L Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. I INFO . 5 a� �3 EH 13-24 REV. 10/82 10/82 500 14-26