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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT W 1601 E. HAZEL T ON AVE. STOCKTON, CA �✓ Telephone (209) 466-6781 AUGERMIT EXPIRES 1'YEAR FROM DATE ISSUED t3 0 9 1990 i (Complete in Triplica'e�,,l;r_jY„ .{� t��'I+ t� rV Application is hereby made to the San Joaquin Local Health District for a permit to gxtrRe.&MfORstall the wS.AN A �JfiH%6C-G�v4plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or N 2 for well/pump and the"t%F€7�.t1 f t StttffiS$1 Baquin Local Health District. n ,•r, } J �� 4!r }1 �f�rw I Job Address ,ie2q _ City lit-Size PM ;_ �1R4NMN r it / �r ]n �r Owner's Name Address`'L Phone Contractor Addressl2ij"�j/V i&L.icense No.<,/r _ ��L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X- OTHER ❑ DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation Dia. of Well Casing IDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }4 FI Public F-1Other P Delta Depth of Grout Seal Type of Grout----- I rout _-I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done % Type of Pump H;P. ° State Work Done -ia. ti Well Destruction T ❑ Well Diameter - 5ealing.Material.;top 5fl') F Depth Filler Material (Below 501 { TYPE OF SEPTIC WORK: NEW INSTALLATION C'l REPAIR/ADDITION i.l DESTRUCTION I I (No 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 ¢ - . l t LEACHING LINE ❑ No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS i I Depth d Size Number _ +r SUMPS.,. ❑ Distance to;nearest: Well. °: Foundation � Property Line DISPOSAL PONDS ❑ i t' 1 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 perforMande 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 I 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." s The applicant must call fgrfil required inspections. Complete drawing on r verse side. Signed Xy„ Title: � _ Date: OR DEPARTMENT USE ONLY f ` D Application Accepted bydK�e��4. Date Of /" Area Pit or Grout Inspection by Date ) Final Inspection byy _ _- Date, Additional Comments: l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O Tracy 835-5385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT'NO. i INFO ♦-EH13-24(REV.1in5) i Q EH 14-2e Q`