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I � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 2 81987 1601 E. HAZE I ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENI M{IE��R HEALTH 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. Job Address 'r` R %`'� � �� City D-el 'e-n Lot Size PM Owner's Name k/ Address ; to /11 .y s Phone �� j Contractor r . / Phone� ddres�� 6PAJLicense No d TYPE OF WELL/PUMP: NE WELL Q WELL REPLACENWhT ❑ 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 C7 Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy' Type of Casing Specifications l Fl Public Cl Other L] Delta Depth of Grout Seal Type of Grout ._ -S) I I Irrigation _..Approx. Depth t I Eastern Surface Sea) Installed by / N Repair Work Done Type of Pump SU-6 H,P. �a- State Work Done L,I"L, _r U.aD) ovrA.Aj Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: :NEW INSTALLATION i I REPAIR/ADDITION l I DESTRUCTION I 1 Mo septic system permitted if public sewer is available within 200 feet.) Instal ion wil�ser-ve: Residence_ Commercial OtherNumber of liveNumber of bedrooms Character of septh of Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation roperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I 1 Depth Size Number SUMPS.- ❑- Distance to nearest: ' Well 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 th San Joa in Local Health District. Home owner or licen e a nt's sig atur certifies following: "I certify that in the performance of the work for which this permit is issued, I shall not ' employ any person i s h nner s to eco bie,ct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin : 'I c rti y the in th pe rrtianee of the work for which this permit is issued, I shall employ persons subject to wofkman's compensa- tion laws of Califor ' The applicant m t II f I: q re ins / s. Complete drawing on reverse side. Signed X Title:.. rn ME Date: R DEPARTMENT USE ONLY Application Accepted by f Date ....... .-'. �� Are Pit or Grout Inspection by Date Final Inspection b Date?_ Additional Comments: I ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMrI�T'NO. iEH13- /IH EH 11-229 •� ZG71C� i /2,-1