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' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601. E, HAZELTON AVE., STOCKTON, CAPERMIT NO. Telephone (209) 456-6781 FIL E C O P DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 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 Regul io s of the San Jo q in cal Health District. Job Address l' bdivision Name Owner's Name: v �1 Address Contractor's Nam r License No. Phone TYPE OF WELL/PUMP WORK; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing ❑ Public [—I Other []Delta Type of Casing Irrigation Approx. ❑Eastern Specifications ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical Type of Grout y OtherSurface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (tap 50') r Depth Filler 'Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION L{ 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 -0oms - Lot size Character of soil to a depth of 3 f et: Water table depth — SEPTIC TANK Type/Mfg Capacity 62©n No. Compartments +� 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 Notal l?ngth/size FILTER BED. , ❑ Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS Depth Size Number i SUMPS ❑ Distance to nearest: Well/ � Foundation Q - Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done An 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 kman compensation sation laws of California." h manner as to become subject to wor § p permit is issued 1 shall not employ any person in suc a p of the work for which - Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance this permit is issued, I shall employ persons subject to workman's compensation laws of California." f The applicarK mustc 1 f all required inspections. Complete drawing on everse side. / Signed X Title: Date Ir (� FOR DEPARTMENT USE ONLY Appl' at ion Accepted by Area ❑ 5tk 456-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date �s 7L �M-anteca 823-7104 Final Inspection by Date 7 �� ❑ Tracy 835-6385 Applicant - Return all copie . to: �Envi onmental Health Permit/Services 1601 E. Haze ton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. INFO -loft 10182 500 E EH 13-24 REV. 10/82 14-26