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APPLICATION FOR PERMIT SAN JOAQUIN:LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA., PERMIT NO. 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 a d Re ulationsgf the San 'Jf in Local lth District. Job Address �b�ivision Name y'1tf � Owner's Name e, ddress O COQ• Phone 2_-3 7�J7 Contractor's Name A' 1"'License No. Phone ! TYPE OF WELL/PUMP WORK: NEW WELL _ WELL REPLACEMENT ❑ DESTRUCTION ❑ } } PUMP INSTALLATION SYSTEM REPAIR Ll OTHER ❑ DISTANCE.TOyNEAREST: SEPTI•C;TANK� - SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATIONS AGRICULTURE WELL OTHER WELL ► PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� Industrial ❑Open Bottom bk<nteca Dia. of Well Excavation I . I �mestic/Private l<r vel Pack ❑ Tracy Dia. of Well Casing 17 Public , - - ❑`Other ❑ Delta T 1 Irri ation Type of Casing LI 9 Approx. ❑ Eastern Specifications `. ❑Cathodic Protection Depth Depth of Grout Seal ❑Geophysical f ; s z Type of Grout ❑Other Surface Seal Installed by o 0-'/ fi hq Repair Work Done ❑ Type of Pump H.P. State Work Done J Well Destruction F-1WellDiameter Sealing Material (top 50') _�Gjfb Depth �~ Filler Material (Below 50') •JJ TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Q Installation will serve: .i 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 Q SEWAGE SYSTEM t—I Distance to nearest: Well Foundation r""" Property Line DESTRUCTION -)M7 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (7). 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 peFson in such manner as to become subject to workman t 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 j this permit is issued, I shall employ persons subject to workman's compensation laws of California." e The applicant must call for.°all required inspections. Complete drawing on reverse side. Signed X ;!! a 1-� Title: y j p�J Date: PARTMENT USE O LY Application Accepted�by Al"n ❑ Stk y,466-6781 Additional,Cortonents: } W ❑ Lodi,,-369-3621 Pit or �ct;io by eo�anteca 823-7104A�-Ir pect ❑ Tracy 835-6385 Applicant =-Ret all co ie E r mental Health ermit Ser es 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ." FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0.• INFO - 0 00 ! g4-} -13-76 EH 13-24 REV. 10/82 10/82 500 14-26 1.