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APPLICATION FOR PERMIT Ll .r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601..E. HAZELION AVE., STOCKTON, CA � . Telepharie (248) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED JUJ_ 19 1988 (Complete in Triplicate) ENVIROMENTAL Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th��r�q�Capplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the u MAIN 1}•�i 11bbE&f the San Joaquin Local Health District. Job Address o UA City 1 PM be 0�,�M Owner's Name Add ss r ' ry Contractor s © ✓� C { 7 _ License No' _6'U Phone �� G TYPE OF WELL/PUMP: . NEWOVELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ;OTHER ❑ DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION r` AGRICULTURE WELL OT1fER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C] Other Cl Delta Depth of Grout Seal k Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done (Type of Pump _� Ite H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 to A fg�A Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet 1 Installation will serve: Residence_ Comfnercial— Other Number of living units: Number a bedrooms r ` Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK ❑ Type/Mfg C city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal !1 Distance to nearest: Foundation Property Line 1 I � V c LEACHING LINE ❑ No. & Length of lines Total length/size. FILTER BED ❑ Distance to nearest: ell oundation Property Line rn SEEPAGE PITS l I Depth Size Number l5' SUMPS ❑ Distance i nearest: Well _ Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. k Home owner icense gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ an person in suc manner as to become s t to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies a following:"I c ify that in t r n of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la of California." The a licant st for all equ' ti s. C e drawin n re rse s' Signe Tit l Date: N Ahv� 1 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection byDate Final Inspection by Date 1� r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO r.EH 13.24{REV.URS) ��^a}�� tf-MV EH 14-26 1 3S