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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG , 9 1988 (Complete in Triplicate) I4VIROMENTAL HEALM Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew fil9lication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RuleaJa ons o t e San Joaquin Local Health District. ��g/ IIIA .,................. �s � f �� Owner's Name Address Phone Contractor Address .,�?ZCR% kl/i-Z--O—k' fes' License No. � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1NSTALLATION,V PJE�Pj/Aa%6YSTEM 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 Dia. of Well Excavation Dia. of Well Casing )d Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I`l Public ❑ Other F1 Delta Depth of Grout Seal Type of Groui . I I Irrigation - ---Approx. Depthl I Eastern gurface Seal Installed by _ Repair Work Done ❑ Type of Pump H. P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') ......,.y _ TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is +4 available within 200 feet.) 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. ❑ I �'Foundation Method of Disposal Distance to nearest: Well Property Line LEACHING LINE ❑ No. & Length of lines Total length/size. FILTER BED ❑ Distance tonearest: 1?G"eli" ` " "" r"-`"F5`urTdatWn Property Line SEEPAGE PITS 1 1; Depth Size _ Number SUMPS L� Distance to nearest: Well— Foundation i Property tine DISPOSAL PONDS ❑ f I hereby certify that I have prepared tKis application and that the work will be,done in e rules and regulations of the San Joaquin Local Health District.; Home owner or licensed agent's signature certifies the following: "I certify that In th� pt employ any person in such manner as to become subject to workman's corripe%isation la, certifies the following: "I certify that in he performance of the w4T,rk for which this permit tion laws of California." _ -^--- �- The applicant s quired- %Complet8Ndraw1J10nIreverse e. Signed X Title." itle. -� Application Accepted by Pit or Grout Inspection by DEPARTMENT USE ONLY. Date Final Insp Date with San Joaquin county ordinances, state laws, and f 1 of the work for which this permit is issued, 1 shall not or'nia." Contractors hiring or sub -contracting signature shall employ persons subject to workman's compensa- Additional Comments: T Date: Area ❑ 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 2000, Stk., CA 95201 «. EH 13-24 (REV. I/ n 5, EH 14-26 Date/ FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT -NO.