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APPLICATION FOR PERMIT ' �` g l Ry +" SAN JOAQUIN LOCAL HEALTH DI 1 1601 E. HAZELTON AVE., STOCKTON, CA Novi 9 � PERMIT NO. Telephone (209) 466-6781 ' ^ PERMIT EXPIRES 1 YEAR FROM DATE AN1sD° JOAQUIN LOCAL DATE ISSUED (Complete in Triplicate) 'HEALTH DISTRICT .� 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' Regulations of t e San oagyj"!^cal'Health District. Job Add ess '` - ,S.^ Subdivision Name OwnerName A. ss 'c Phone Contractor's Name icense No. Phone r .4. TYPE OF WE WORK: NEW WELL WELL REPLACEMENT ❑ ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ W1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE . I� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ - In ustrial Open Bottom r ❑Manteca Dia. of Well Excavation � [J_ stic/Private ❑Gravel PackTrac ❑ Y Dia. of Well Casing 17 Public ❑ Other ❑ Delta ❑ Irrigation Type of Casing Approx. [:] Eastern ❑Cathodic Protection Depth Specifications ❑Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done.; Type of Pump H,p, I V_2 State Work Done Q Well Destruction-❑ Well Diameter Sealing Ma erial (top 501) u� ' I Depth Filler Material (Below 50') , J� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Number of liviing units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK 11� ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM f Distance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE .11: ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS° - Depth - - p Size Number � li 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 person in such manner as to become subject to workman compensation laws of CaTiforniI'" Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is i ued, I shall employ persons subject to workman's compensation laws of California." The applicant t call for qu're in ection om t dr i g n rev rse id . Signed X Date: 1 H b -B I� FOR TME U$E LY 1 Application Accepted by �, � Area ©4 ef-Stk 466-6781 Additional Comments: ❑ Lodi 369-3621 Pit or Gaut Inspection by Date ❑ Manteca 823-7104 .i Final Inspection by Date - !Str ❑ Tracy 835-6385 Applicant - Return all copies to: Envirol6entaT Health Pert/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I ' FEE BASE AMOUNT DUE AMOUNT REMITTED !RECEInVEDBY INFO PERMIT N0. IN �� S-- J_:::DATE 1-I'�-�� 9 0 EH 13-24 REV. 10/82 126 10/82 500 ' 4-