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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 P C 1/O IJ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r „ 4 .L. (Complete in Triplicate) . `0 0X Ze d.9 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. t--G� A� Leo m oQ-0 Job Address °0 /�• ',� '� City Lot Size PM � IFS- f�i0Phone � :O Owner's Name _ "'' '`- �'�f�e" d ess zz r Contractor's Name =� r License No. Phone TYPE OF WELL/PUMP: 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ",E3 Other El Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern ;Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 50' 1 t Depth _ 3 "'--Filler-Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is `^---� available within 200 feet.) Installation will serve: Residence�,•- Commercial Other s. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r fa ' ' N Water table depth V P SEPTIC TANK R Type/Mfg °a Capacity « d No. Compartments PKG. TREATMENT PLT.'❑, i f / . Method of Disppsal D'i`stance to nearest:"' Well /50 Foundation�/-[=1- � Property Line e LEACHING LINE No. & Length of lines ,/CSO . . t ptal /length/size- !VJ FILTER BED F1 Distance to nearest: Well Foundations*..-_Property Line I SEEPAGE PITS Depth ize N ber °n Y. 1 fv ti\ UMPS ❑ Distance to nearest: Well_` Foundation'`�' Property Line l SAL 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 workman's compensation laws of'Calif ornia."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 parsons subject to workman's compensa- tion laws of California." The applicantSust call for all re ire inspections. Complete drawing on reverse side. r. �. Signed XM., Title: Date: FdRD ARTMENT USE Q pWLY Application Accepted by. Date -��A_ Area Pit or Gr6ut Inspection bye % Date -4 4 'Final}n cti,n by Date Additional Comments: ❑ Stk 466-6781 - §Lodi 369-3621 t Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE * AMOUNT REMITTED K H RECEIVED BY DATE. PERMIT"N0. INFO +EH 1324(REV.10183) �- �© J�"`/Leo / �• "' `3� IR EH 1426 . r