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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELION AVE., STOCKTON, CA Telephone (209) 466-6781 APR 13 1,987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 &a JCity Lot Size PM Owner's Name w4(tAddress 1I �2 — , � Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEM NT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 4N11P, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS zip ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )(Domestic/Private X Gravel Pack 1wTracy Type of Casing—_ f1VL',, Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 6'0'-f- _ . Type of Grout ❑ Irrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will sbmm--Residence— Commercial_ Other Number of living units: Num of_bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: WellFoundation roperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, 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." The applicant ust call for all re uire 'nspections. Complete drawing on verse de. Signed Title: Date: FOR iDEPp TMENT USE ONLY l� Q� [� Application Accepted b ' � y� Date �� i'u i Area ` Pit or Grout Inspactio Date Final Inspection by Date 4(,774 Additional Comments: !�/� Of4 ❑ Stk 466-6787 CA! 368-36'11 11 Manteca 823 71 4 ID Tracy 83x6385 SCJ . Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bo4gU6tft, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. 4= 1A ( � + EH 14-241REV.t/ssl /�.c9c7 [�� LIN, L�1� t."7�p �r SDID EH 14-28 G ! LI , L I