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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. V�/ Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 an Joaquin Local Health District. Job Addresses ] lam '�(� Subdivision Name Owner's Name "", Address Phone Cgntr ctor',s Name'' LkLicense No..� �� r Phone TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ (J\` PUMP INSTALLATION ❑ SYSTEM REPAIR, ❑ OTHER ❑ DISTANCE TO NEAREST:_SEPTIC TANK SEWERIINES_. DISPOSALFFLD. PROP, LINE _ FOUNDATION RGRICULTURE WELLOTHER R WELLPITS/SUMPST U� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 0 Industrial U Open Bottom F1 Manteca Dia. of Well Excavation L_l Domestic/Private ( G�rav�jl.Pack Q Tracy _ _ _ Dia. of Well Casing_ 4,4 Public [j Other ❑ Delta T ype of Casing Li Irrigation Approx. Eastern z Specifications Cathodic Protection Depth Depth of Grout Seal 1-1 Geophysical Type of Grout F-1Other �------- Surface Seal Installed by f Repair Work Done [] Type of Pump H.P. r State Work Done Well Destruction Well 'Diameter`. ' fr U '""1 Sealing Material.(top 50;}L Depth c----l-id-ler Material (Below )! ; z TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION .E (No septic tank or seepage"pit permitted if public sewer is '� available within 200 feet.) Installation willjser'v6::� Rfes Bence Commercial Other Number of living units: Number of bedrooms Lot size1.�'C� Character of soil to a depth of 3 feet: [� a� Water table depth 5EPTIC TANK ❑ Type/Mfg ; Capacity No, Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Q Distance to nearest: Well Foundation Property Line DESTRUCTION c LEACHING LINE No. & Length of lines Total length/size FILTER BE'iZ, Distance to nearest: Well Foundation Property Line SEEPAGE PITS-- .' Depth , 6 Size ?jam Number SUMPS ❑1 Distance to nearest: Well Lundation Property Line DISPOSAL PONDS ❑ t 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 shal'1?not employ any person in such manner as to become subject to workman t compensation laws of California." Contractor's hiring or�subicontracting signature certifies the following: "I certify that in the performance of the work for which this ;permi•t is issued, I1. 9-employ persons s bject to workman's compensation laws of California." The applica LSP ust`c. 1, 'f r 1. to ecti ns. Complete dr wing.o r �y, .` .� Signe Title: °I A� a/ Date: t, � t� FUSE ON /} r Application Accepted b MW �-� r� �� Stk 466-6781 Additional Comments: f ❑ Lodi 369-3621 Pit or Grout Inspection by Date f _ -_� �J Manteca 823-7104 Final Inspection by "' Date ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., .0. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT.:NO. INFO EH 13-24 REV. 10/82 } 10/82 500 14-26