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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. g3'-11 3 7 Telephone (209) 466-6781 DATE ISSUED l- 3 I 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 and Regulations of t e San u' Health District Job Address• �A \ ion Name �J�1L/ I Owner's Name �ddress CJ ' phone `r z Contractor's Name License No. Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ „ PUMP INSTALLATION ❑ SYSTEM REPAIR j❑ OTHER i] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation !, Domestic/Private LJ ❑Gravel Pack ❑ Tracy Dia, of Well Casing ❑ Public ❑Other ❑Delta I Type of Casing F-1Irrigation Approx. ❑ Specifications Eastern , [:)Cathodic Protection Depth Specifications Depth of Grout Seal I ❑Geophysical ❑Other Type of Grout 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 INSTALLATION 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 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK [, j Type/Mfg Capacity No. Compartments S.- PKG. 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 1 gth/size Q FILTER BED ❑ Distance to nearest: Well Foundation @ Property Line f SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ k 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 Lqcal 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 empl y persons subject to workman's compensation laws of California," The ap is t must call all a ed inspecti Complete drawing on side. { Signed X Title: �? Date: vt, — FO ARTMEN USE ONLY Application Accepted by Area 466-6781 u Additional Comments: S S t O Lodi 369-3621 Pit or Grout Inspection by Date Manteca B23-7104 Final Inspection by Date — /J 3 ❑ Tracy 835-6385 Applicant - Return all copi s to: Enviro mental H lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY I DATE �PERMIT NO. INFO �� 1oi( Fs3 3 -113 Lis FSH 13-24 REV. 10/82 I, 10/82 500 T .. .+ a 14-26