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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZERON AVE., STOCKTON, CA C) Telephone (209) 466-6781 flc� PERMIT EXPIRES 1YEAR FROM DATI� > SEDv 3.5 �JAL N ALTH (Complete in Triplicate) ct an r ir>fs� h. ork herein described.This application is" Application_is hereby made to itie San Joaquin Local Health District for a permit to construct and Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well ' r T �� Local Health DistrrictzMCe, City Lot Size PM Job Address I I Address- Phone Owner's Name - Contractor ' Address ! �� _ ..License No. Phone TYPE OF WELL/PUMP: �L NEW WELL WELL REPLACEMENT _DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i4L�FL-D.-==—`PROP�HNE.,�.�..,- --• r DIST TO_ NEA fiEST:'SEi1�TIC-TANKF 'SEWEft'tiNE�s' _ t FOUNDATION. AGRICULTURE WELL OTHER WELL PITSISUMPS r, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS II C L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2� Dia. of Well Casing „F. Specifications ❑ Domestic/Private JeGravel Pack ❑ Tracy Type of Casing / Type of liC ] - 'I' Depth of Grout Seal Public ❑ Other F1 Delta P �j l I Irrigation �_Approx. Depth l i Eastern �S7urfja a Seal'Installed by rf)I'l��k ILA'_Tn_ ` i` H.P. f ��" State Work Done Repair Work Done- ❑ -Type of Pump �6.K.L�— i Well Destruction ❑ Well Diameter - Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I;I REPAIR/ADDITION 1.1 DESTRUCTION [ I ave septic system permitted if public sewer is available-within 200 feet.) installation-will serve: 'ResidenceCommercial Other Number of living units: L Number'of bedrooms (� l Character o1 soil to a depthof 3 feet: + ' Water table depth ...r^ h SEPTIC TANK D .Type/Mig 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 - Pro"Y ert Line V FILTER BED ❑ Distance to nearest:' Well Foundation Property Size t Number SEEPAGE PITS I Il� r6t Depth - F �._ .,�,. -'SUMPS" t� IIII Distance to n'eorest:!"rvveil--� � 'Foundation ProperWUne i DISPOSAL PONDS ❑ .[ r V1% I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsand , rules and regulations of the Sian 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 mender as to became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any parson in such certifies the following: "I certif /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 Cal, The applica mus a r all require io . Co I to drawing on fever de: I Facility P1 annerDate: 9/30/87 Signed X Title: 11 1 (j Fury O 'E arr FOR DEPARTMENT USE ONLY Applic tion Accept d by I Date / Area011� ' Q Pit or Grog,Inspection by t, Date ` Final Inspection.by - `' Date Additional Comments: II� ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. INFO II . EH 13.241REV-t/Kbl 4 �1 [J S� 4- 10 S EH 14-2e- IIFFF . 4. . _. --