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�Q APPLICATION FOR PERMIT pg1(='MENT SAN JOAQUIN LOCAL HEALTH DISTRICT R E C E I V E D 1601 E. HAZELTON AVE., STOCKTON, CA MAR 1 -) 1988 Telephone QW) 466-6781 -Si a i PERMIT EXPIRES 1,YEAR .FROM DATE .ISSUED ., ENVIRONMENTAL HEALTH 4 (Complete:infriplicate) PERMITISERVICES 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. ; �. /h Job Address [IJ - City of Size _ PM Owner's Name lr J Address Phone r� Contractor C- Address/ ZZ-L License No.-q-6.� Phone V" TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing [� !a Domestic/Private ❑ Gravel Pack 17 Tracy Type of Casing Specifications E) Public Ll Other Q Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx. Depth h O Eastern Surface Seal Installed by Repair Work Done ® Type of Pump H.P.1'1% _ State Work Done 21" 90JF Well Destruction C1 Well Diameter Sealing Materiai (top 50') 40! Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1, • . available within 200 feet.) Installation will serve: Residence_ Commercial_ Other (/y Number of living units: Number of bedrooms L� Cy Character soil to a depth of 3 feet: Water table depth ' SEPTIC TANKK LJType/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 ❑ Depth Size Number SUMPS 171 -Distance toinearest:-r --'Well V �* %, -`,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. r �' v - Home owner or licensed agent's signaturecertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not f 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." The applicant rpust gall f all required inspections. Complete drawing on reverse side. Signed X Title: Date: /' EPA ENT USE ONLY Application Accepted by Date c�� Area Pit or Grout Inspection by Date :Final Inspection by I Additional Comments: _ ID SW-4613,6781 - 0 Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 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 PERMIT`NO. /� . + EH 13-24 IM.1/e 5) �S X66 EH 1426