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�l APPLICATION FOR PERMIT ' l y SAN JOAQUiN LOCAL HEALTH DISTRICT OCT — �� I 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. Telephone (209) 466-6781 � 2 SAN JOAQ!,"N L(,%!--AL DATE ISSUED ATE PERMIT EXPIRES 1 YEAR FROM DISSL��LTH D1STRICj (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 the SanJoaquin Local Health District. Job Address S 5b 1J Subdivision Name Owner's Name AArX J?GJ./ Address Phone Contractor's Name.— ti SQ License No. �?gO/D Phone �22y7 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION CA PUMP INSTALLATION SYSTEM REPAIR .R OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation r�iJ Domestic/Private Gravel Pack Tracy Dia. ofWellCasing Public jOther Delta Type of Casing Ljirrigation Approx. ❑Eastern Cathodic Protection Depth Specifications Depth of Grout Seal ❑Geophysical Type of Grout ❑Other Surface Seal Installed by Repair Work Done Ug Type of Pump Sc.� H.P. 1 State Work Done f Af 1,ee,.-eoP v Well Destruction ❑ Well Diameter Sealing Material (top 501) _ J 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.) Installation will serve: Residence _ Commercial _ Other Number of living units: . Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water, table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line DESTRUCTION ❑ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 permit is issued, I shall not employ any person in such manner as to become subject to workmanis 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 employ persons subject to workman's compensation laws of California." The applica m st all for 1 re red inspections. Complete ing on reverse side. Signed X ✓ Title: ��Q�.1 Date: �"— fOR DItTUSE ONLY Application Accepted by !n USE O Q,M.._Area Stk 466-6781 Additional Comments: Lo 1 369-3621 Pit or Grout Inspection by Date ❑ anteca 823-7104 Final Inspection by n 'r{ Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health ermit/Services 16 E. azelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED (� � RECCEIVED BY —DATE^p? -q PERMITI N0. INFO I �/Y Q`� l7—eJ O3��l � EH 13-24 REV. 10/82-'j I 10/82 500 14-26