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� APPLICATION FOR PERMIT D 1 SAN JOAQUIN LOCAL HEALTH DIST CT JUN 7 1988 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIROMENTAI_ HEALTH F ' PERMIT EXPIRES 1 YEAR FROM DATE ISSE)MAIT/SERVICES t ' I (Complete in Triplicate) Application is hereby made 1,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 .% oaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. . 77"i� /C � F` Cit �7�, Job Address y Lot Size �� PM I�I I ^-- I Owner's Name i w/�Sa Address �i� - - Phone :Fw= Z Contractor QQQJ��/j s �y _Address�� G",LL'j2Ln AZ'aicense No. j Phots e TYPE OF WELL/PUMP: ilp NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION PIU.MP INSTALLATION �7� �� SYSTEM REPAIR OTHER ❑ Jl. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE NTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑!Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing "Domestic/Private OE Gravel Pack L1 Tracy Type of Casing Specification i 1-1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I Irrigation -Approx. Depth i I Eastern Su ace Seal Installed by Repair Work Done ❑ Type of Pump H.P. L State Work Done )C'07_4FA 'Q CgazIlill Well Destruction ❑ Well Diameter Sealing Material {top Depth Filler Material (Below 50'1 O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Flsidence_ Commercial_ Other -11 a r Number of living units:. 0 Number of bedrooms .r I Character of soil to a depth of 3 feet: /. Water table depth SEPTIC TANK 01 Type/Mfg ��apacity_ No. Compartments PKG. TREATMENT PLT. ❑ - l Method of Disposal �M } Distance to nearest: t Well :i Foundation Property Line LEACHING LINE ❑' I No. & Length of lines rTotal length/size FILTER BED ❑ Distance to nearest: Well `l Foundation Property Line SEEPAGE PITS i I I Depth= = Siz . Number ' SUMPS ❑ 'Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ I hereby certify that I have p`,repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San Joaquin Cocal Health District. 11 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 su`b-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 workman's compensa- tion laws of California." The applicant r I requ' tions: Complete drawing on rev rse ide. A Signed X -� � �IeF � �ef.L�� Date: p F Fi DEPARTMENT USE ONLY Application Accepted by �,�[. -�-.[�'+- Date Area, I' Pit or Grout Inspection by '�! Date Final Inspection by //L _- I� Date a Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copieslslto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PE MIT•NO. INFO � CASH p p H,, L� /� } + EH}3-24 rpEV.i i n 51 �J? -V� C rpm j�-"d ! O i � o EH 14-28 H