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APPLICATION FOR PERMIT *a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 Pel n. + 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) 1 Q 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. l�Z� �• � SIJ Job Address /I City Lot Size P ly P Owner's Name P S Address Zgx 0h- ' J(0 Phone -7`9 l Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE FOUNDATION A TUBE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS % ❑ Industrial EI Open Bottom E3 Manteca Dia. ell Exc 'on Dia. of Well Casing Cl Domestic/Private D Gravel Pack ❑ Tracy pe of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation - rox. Depth ❑ Easte Surface Seal Installed by Repair Work Done ❑ Type of Pump✓ AREA State Wark Done A Well Destruction ❑ Well Diame�er: Sealing Material (top 501 Depth —Filler-Materiaf_(Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is R available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: -I— Number of bedrooms Character of soil to a depth of 3 feet: 14,9 w" Water table depth SEPTIC TANK D�,Type/Mfg L Cc C4 Capacity dU No. Compartments 2 PKG. TREATMENT PLT. ❑ , I Method of Disposal --" -Distance to nearest: Well,Z00 Foundation [-9 r � � Property Line (-- LEACHING LINE -No. & Length of lines a I Total length/size FILTER BED .,.�❑ Distance to nearest: well2�- Foundation Property Line_f�Q SEEPAGE PITS ❑ Depth Size 4V.NeNumber SUMPSDistance to nearest: Well 1e2W2&k_Foundation Property Line DISPOSAL PONDS ❑ 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not T 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, I shall employ persons subject to workmn's compensa- tion laws of California." '`"'rhe applican ust call-fbr all requir_e_a inspections. Complete drawing on reverse side. I figned Title: Date: ,. FOR DEPARTMENT USE ONLY -yAccepted by �r Z.ry�T Date Area Inspection by Date Final Inspectionby �'�- Date .2 .wnments: ❑ 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 2009, Stk., CA 95201 V FEE AMOUNT DUE"� AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH +EH 1324 1REV.10/83) EH 14-28