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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA i. Telephone {209) 466-6781 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 San Joaquin Local Health District. 1 ik, Job Address vY L�-,,p CA r Oyu.L �+q_ City Lot Size PM ! Owner's Name Address �7.�1 �.Le-Q, Phone ' ��a L-" Contracto Address / License No. Phone r TYPE OF WELL/PUMP: Y NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -❑ Manteca Dia. of Well Excavation 't _- -'-Dia."of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t'E Public t=1 Other ❑ Delta Type of Grout Depth of Grout Seal I I Irrigation' .Apprgx. Depth -1 } Eastern Surface Seal Installed by ' Repair Work Done ❑ Type of Pump r_ H - State Work Oone- 4 Wel! Destruction ❑ Well Diameter Sealing Material Itop 50'1 ' V Depth Filler Material (Below 501 j r TYPE OF SEPTIC WORK: NFWJNSTALLATION I.I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sower is -available within 200 feet,I Installation will serve:-Residence ^Commercial Other "�' ��-- - Number of living units: "Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ! SEPTIC TANK ❑ Type/Mfg Capacit y No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal r' t- Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED r ❑ Distance to nearest: ' Well Foundation Property Line b , SEEPAGE PITS I I Depth Size Number SUMPS k.; Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law ' rules and regulations of the San Joaquin Local Health District. s, and 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 workman's 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,t shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X /� Q Title: _� _ Date:/Ii - S02 FOR DEPARTM T USE ONLY Application Accepted by Date Area Pit-or Grout Inspection by Date )nal Inspection by x-•e t.�.�,� �J Date Additional Comments: �t�ytr L �D5 Z ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2W9, Stk., CA 95201 �^(� FEE AMOUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE( pgRMIY'1V0 I * EH 13-24 1flEV.tins) EH 14-26 /� d7Y � CEJ U