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(?�vh q-r,a Ga rc► a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL,HEALTH DISTRICT 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '. a {Complete in Triplicate} Application is hereby made to the San Joaquin Local Health District fora 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 San Joaquin Local Health District. Job Address N94 � � Subdivision Name Owner's Name Address �YY\L',E Phone ILicense No. Phone k Contractor's Name TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION [ ] PUMP INSTALLATION F-1 SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'f Industrial - U Open Bottom []Manteca Dia. of Well Excavation N L_I Domestic/Private Gravel Pack [� Tracy Dia. of Well Casing Public # # [-j Other ` . [] Delta Type of Casing r Ll Irrigation Approx. []Eastern Specifications ��nn Cathodic?Protection Depth Depth of Grout Seal vl Geophysical Type of Grout U Other + _ ' Surface Seal Installed by H.P Repair Work Done G Type of Pump . State Work Dane Well Destruction ❑ Well Diameter,: Sealing Material (tap 50') i Depth } Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit avapermitted ilable-withinpublic feet.) is Installation will serve: Residence Y Commercial Other Number of living units: j_— Number of bedrooms -Z Lot size ,�,,// Water table depth Character of soil to a depth of 3 feet: r1 6C , A Capacity No._ No. Compartments v SEPTIC TANK Type/Mfg PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION r LEACHING LINE No. & Length of lines Total length/size i FILTER BED Distance to nearest: Well Foundation �� Property Line SEEPAGE PITS - Depth Size Number rPro erty Line SUMPS �� Distance to nearest:. Well Foundation p DISPOSAL PONDS 4 I hereby certifthat Ishave prepared this application and that the work will be done.an accordance with San Joaquin county y ordinances, state.laws, and rules and regulations of the San .Joaquin Local health District. Home owner or licensed agent's.1signature-certifies the fo owing: "I certify that in fhe performance of the work for which this permit is issued, I shall"not„employ any-person in such manner-as to become subject to workman compensation laws of Cal.ifornia.” 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-Califo'nia." r The applic t must call for 11 required inspections.—Complete dr i g on reverse side. l Date: Signed X Title: t F DFPA TMENT USE ONLY /) Stk 466-6781 licatien Accepted Area (/__ __ Lodi 369-3621 Additional Comments: Manteca 623-7104 I Pit or Grout Inspection b Date FinalInspectionby Date -��:� ❑ Tracy 835-6385 Applicant - Return all,-Copies +to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT NO. Ta- 10/82 500 LH 13-24 REV. 10/82 14-26