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V APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL.HEALTH,DiSTRICT f 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (Complete in Triplicate) PERMIT NO. T4 f�-�� DATE ISSUED 9'2�� 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 and Regulations of the San Joaquin Loc 1 Heal h District. �- Job Address 1:1.bdivision Name Jl Owner's Name Address ' r one Contractor's Name License No.'r Phone TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR U OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J Industrial U Open Bottom Manteca Dia. of Well Excavation L_I Domestic/Private Gravel Pack Tracy Dia. of Well Casing �] Public F-10ther Delta Type of Casing ❑ Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material -(top 50') _ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) installation will serve: Residence X Commercial _ Other Number of living units: _,-- Number of bedrooms Lot size �rpt of 3 fee Water table depth �(J Character of soil to a d SEPTIC TANK T g Capacity No. Compartments �+ PKG. TREATMENT PLI. � Type/Mfg Capacity rte_— Method of Disposal SEWAGE GESSYSTE ON o Distance to nearest: Well �/-J Foundation Property Line �'1 LEACHING LINE �✓ rea No. & Length of lines Total length/size f Stk' FILTER BED ❑ Distance to nearest: Weil Foundation `- Property Line! 0 SEEPAGE PITS i.� Depth �f- Size Number SUMPS El Distance to nearest: well Foundation Property Line - A Date DISPOSAL PONDS ❑ Tracy _835-6385 I ' Applicant - Return all copies to: 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 1s compensation laws of California." Contractor's hiring or sub -contracting signature certifies the'foTlowing: "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 t c i for all.�req it d in spec ons. Complete drawing o rse i w Signed X A Title: Date: vZ FOR DEPA TM E ONLY Application Accepted by �✓ rea AMOUNT DUE LJ- Stk' 466-6781 r Additional Comments: INFO l f 0 Lodi 369-3621 } Pit or Grout Inspection by 2 Date g LD Manteca 823-7104 Final Inspection by A Date ❑ Tracy _835-6385 I ' Applicant - Return all copies to: Environmental Health Pe mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO l f EH 13-24 REV. 10/82 14-26 Q-1 10/82.500