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low APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA E � . Telephone (209) 466-6781 E "EE PERMIT EXPIRES TYEAR FROM DATE ISSUED MAR 1 1991 (Complete in Triplicate) ENVIRONMENTAL Hf EALTH r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worpERM4T.4$ p.iVAlC lication is s 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. Ilk _Job Address Cit Cit Lot Size PM Ut e r Owner's NameAddress Phone r r F Contract Address 1.1 License No zz6 Phone _,5/d TYPE OF WELLIPUM NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 _Y FOUNDATION,- AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing CD Domestic/Private ❑ Gravel Pack/ © Tracy Type of Casing Specifications M Public C Other : f_f❑ Delta Deptki of Groul'Seal Type of Grout I I irrigation ---Approx. Depth' 1`IfEastern Surface Seal Installed by V Repair Work Done ❑ Type of Pump 'r ; H.P. rz State Work Done Wel! Destruction ❑ Well Diameter 4 4 Sealing Material atop 50'1 r` Depth Z ' r Material l-eel-w-50-T-1 -- i' TYPE OF SEPTIC WORK: NEW INSTAL TION I I '<R PAIR/ DDITION DESTRUCTION I I Wo septic,system permitted if public sewer is /'t • available Within 200 feet.) n(� t Installation will serve: Residence Commercial t,Other AA Number of living units: -/— Number be roo s Character of soil to a depth of 3 feet: , Water table depth SEPTIC TANK ❑ Type/Mfg capacity-/---, rt No. Compartments I PKG. TREATMENT PLT. ❑ ' , fi Method of Disposal i Distance to nearest; Well Foundation _ ,P_roperty Line fi ! / LEACHING LINE X No. & Length of lines '� p :• Total length/size K FILTER BED ❑ Distance to nearest: Well. Foundation .. _ Property Line c� SEEPAGE PITSDepth Size Nymbor 4z . SUMPS L1 Distance to nearest: Well�Q_._ Foundation Property Line DISP05AL-PONDS'_ ❑ I hereby certify that I have prepared this application and that the work will be done in_acco�dance with San Joaquin county ordinances, state laws, and rules and regulations.of the San Joaquin Local Health Di§trict. 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 applica st call f all Aeqd inspections. Complete drawing on rover e Signed X Title: �_. --_ Date: - +-=- - FOR DEPARTMENT USS ONLY �(��]n �� s Application Accepted by Dated _t v `� Area or-Grout-Inspection by -it;�� YLs.. Data - / Final inspection by Date Additional Comments: t ❑ Stk 466.6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. INFO 27 41 ♦.EH13-24MEV.r/851 ✓ ��1 Y \ -6�;13 EH 14.26