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F SAN IOAQUIN LOCAL 14EALTH DISTRICT ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED - 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 1988 I (Complete in Triplicate) .ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thewJ?E Th/&&I GE9hiS 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 _/ _J 74917 l , C-® City _riy��y Lot Size PM Owner s Name fia `--'U"4 Address �� " ` r� J'..V,!:: - Phone J � Contractor !r/ >:+�i` c"Address 2^s�'L License No Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Q PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �.-.._ SEWER LINES Z�� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS ndustrial L1 Open Bottom C1 Manteca Dia. of Well l xcavat- n Dia. of Well Casing G %SGC Specifications k ❑ Domestic/Private �T Gravel Pack ❑ Tracy Type of Casing Spec /��_� f-I Public !r/a�'�'i Othe��(l�T n Delta Depth of Grout Seal Type of Groutr lgilf i € 111 Irrigation _.-Approx. Depth III Eastern Surface Seal Installed by L' Repair Work Done L] Type of Pump SCIldn-- H.P. l State Work Done_ Well Destruction ❑ Well Diameter Sealing ateriail Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 :REPAIR/ADDITION L I DESTRUCTION I I INo septic system permitted if public sewer is 'F available within 200 feet.) j 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS ! I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL 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 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 workman's compensa- tion laws of California." 411 The.applicant must c II f required f plate drawing on rev se side. r Signed X Title: Y�✓�/ y Date: F R DEPARTMENT USE ONLY ' Application Accepted by " date 900 Area Pit or Grout Inspection by Data Final Inspection by Date& , Additional Comments: e— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca M-'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 ASH RECEIVED BY DATE PERMIT-NO. INFO I +.EH 13-24(REV.IJRsl EH N-25 45�� 1 f_&_4_eK_T IVIW