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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 �- — DATE ISSUF.O PERMIT EXPIRES I YEAR FROM DATE ISSUED !(Complete in-Triplicate) in•Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 1 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 Re�g+ulationns� of the San oaquin Local H 1th.District, Job Addresy�r"Ty'7 �a( ji�AAL9�.v, Subdivision Name Owner's Name Address y Phone k Contractor's NameLicense No,gi s� r °hone - TYPE OF WELL/PUMP WORK: INEW,WELL (] WELL REPLACEMLNT ❑ DESTRUCTION❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK, SEWER CLINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL% PROBLEM AREA CONSTRUCTION SPECIFICATTDNS J Industrial ❑Open Bottom ❑Manteca- Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack Tracy$ Dia. of Well Casing ❑Public ❑Other Q Delta.- Irrigation Type of Casing F, 9 � Approx. '�Eastern Specifications Cathodic Protection Depth ❑Geophysical Depth of Grout Seal Type of Grout f Other _ {? _ L .� Surface Seal Installed by T Repair Work Done-L] Type of Pump ` 'L H.P' r State Work Done Well Destruction [] Well Diameter Sealing Material (top 50') ._ .:Depth. Filler Material (Below 50') F TYPE OF SEPTIC WORK: NEW INSTALLATION (J 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 I: Character of soil to a depth of 3 feet: Water table depth U f SEPTIC TANK ❑j 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 Totaf length/size FILTER BED Distance to•nearest: Well Foundation '-- Property Line SEEPAGE PITS ❑ Depth Size Number , SUMPS ❑ Distance to nearest: Well Foundation; 46--4-• Property Line i 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 workman5 coinpensation 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 applicant must call r a r qu d inep tions. Complete dra g nn reverse side. Signed X Title: y Date: %X PARTMENT USE ONLY �7 Application Accepted by -- 1 Area o7 .-- ❑ Stk 466-6781 Additional Comments: [] Lodi 369-3621 Pit or Grout Inspection b -_ Date ❑ Manteca 823-7104 r Final Inspection by Date Tracy 835-6385 Applicant - Return all copies to.. Envi onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE . AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. rfr; INFO ' L1J-1-7 EH 13-24 REV. 10/82 �'1 10/82 Soo 14-26 4.