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APPLICATION FOR PERMIT nriO LD �.� SAN JOAQUIN LOCAL HEALTH D15TRICT !f 1601 E. HAZELTON AVE.,�STOCKTON, CA PERMIT NO. !J� 3 Q v Telephone (209) 466-5781 p fft DATE ISSUED l' PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED (Complete in Triplicate).' r 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 Local Health District. ,` L Job Address S'- Subdi0 sion. Name N r Owner's Nam Address Phone 46 Contractor's Nn eve/ License No. - phone (./`7 TYPE Of WELL/PUMP, WORK: NEIJ'WELL F-1WELL REPLACEMENT DESTRUCTION U °PUMF. INSTALLATION SYSTEM REPAIR OTHER U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION ;F AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE':OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS industrial U Open Bottom F-�Manteca Dia. of Well Excavation LJ Domestic/Private E]Gravel Pack Q Tracy Dia. of Well Casing 1 Public Cj Other ❑Delta Type of Casing L-; Irrigation Approx. ❑ Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal Geophysical § Type of Grout U Other * Surface Seal Installed by f 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/ADOITION U (No septic tank or seepage pit permitted if public sewer is 1. 14 available within 200 feet.);, Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms _S-1 __ Lot size C/ / Water table depth. Character of soil to a depth of 3 feet: o� n SEPTIC TANK X °Type/Mfg -Raca to Capacity _/2_c7,O No. Compartments �f) PKG. TREATMENT PLT. [1 Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM - Dista ice to nearest: Well,_ Foundation / - Property Line DESTRUCTION . s ( LEACHING LINE ) No. &;Length of lines ��JTotal length/size v '— FILTER BED Distance to nearest: Well /syCP Foundation Property Line SEEPAGE PITS Depth[ Size Number _:z_ SUMPS L l Distance to nearest: Well - Foundation Property Cine DISPOSAL PONDS �I ` 7r I hereby certify that I have .�p..repa•red this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and�r.0-)es'and regulations of the San Joaquin Local Health District. Home owner or licensed agent-"!;, 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 became subject to workman compensation laws of Californiac i Contractor's hiring or sub-contracting=signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shal7Ae'mp16y persons subject to workman's compensation laws of California." The applicant must call f al equi,r in ections. Complete drawin on reverse side. Signed X Title:\ Date: • _ r EPARTMENT USE.ONLY' l tk 466-6781 >, Area Application Accepted by .. ❑ ,t Lodi 369-3621 Additional Comments: r i Manteca 823-7104 Pit or Grout Inspection by yt Date �� U I -" a L7 Tracy 835-6385 Final Inspection by J Date��' Applicant - Return all copies.to:,+ Environmental Health rmit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED BY DATE �7 PERMIT NO. INFO O 3 -T7 7 10/82 500 EH 13-24 REV. 10/82 1 l 14-26v