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APPLICATION FOR PERMIT F SAN JOAQUiN LOCAL HEALTH DISTRICT + 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.� 6 Telephone (209) 466-6781 j DATE ISSUED(qIV-) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I (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 Joaquin Local Health District. Job Address y Subdivision Name k I Owner's Name Address Phone e I Contractor's Name L' ense No. -2 Phone TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR ] OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD. PROP. LINE' S FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pen Bottom El-Manteca } .f - 1 Dia, of Well_Excavation,.m:..r:/e�- -..---- � f- U Domestic/Private Gravel Pack Tracy ; Dia. of Well Casing f �LJ ' F-1Other Delta Y Type of Casing - '��L_ rrigation Approx. Eastern Specifications [Cathodic Protection Depth Depth of Grout Seal U Geophysical Type of Grout U Other Surface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Materialw(top 50') k Depth Filler'Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION LJ (No septic tank or seepage pit permitted if public sewer is (] available within 200 feet.) C Installation will serve: Residence Commercial _ Other f� Number of living units: Number of bedrooms Lot size lJ Character of sail to a depth of 3 feet: ' Water table depth SEPTIC TANK EJ Type/Mfg r Capacity No, Compartments PKG. TREATMENT PLT, j] Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: 14e3l Foundation Property Line DESTRUCTION.- LEACHING LINE U No. &. Length.of-,lines t Total length/size FILTER BED, Distance to nearest;., Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMP U Distance to nearest: Well Foundation Property Line r 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 j permit is issued, I shall not employ any person in such manner as to become subject to workmant 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 e loy persons subject to workman's compensation laws of California." The appli an st call for al equir inspections. Complete dra.wi n e side r- Signed X Title: Date: FOR DE RTM T USE NL is tion Accepted by Area Stk 466-fi781 Additional Comments: p > Lodi 369-3621 Pit or Grout Inspection b Date f Manteca 823-7104 Final Inspection by Z Date [ Tracy 835-6385 -Appli.cant..-,Retor.n,all„copies to; Environ ental Health Permit/Services 1601 E. HaOoltn Ave., P.O. Box 2009, Stk., CA 95201 [FFE. -BASE- -.- AMOUNT-- DUE -. AMOUNT REMITTEb .'...-JECEIVED,BY DATE „•?FRMTT.No. INFO ems. q a �3 -96 EH 13-24 REV. 10/82 10/82 500 14-26