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r•+ I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 T 3 0 X987 PERMIT EXPIRES 1,YEAR FROM DAT D t W (Complete in Triplicate} ttiill ; p ENVIkUrrE!vIAL HEALT11 Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or insttla erei�r �mprl-Th�g�Rp1i>gtion Is made in compliance with San Joaquin County Ordinance No.549 for sewa e r o. 1862 for well/p1 ttd Re ulations`of t e an aquin l Local Health District. � � ` 1N _ Job Address ` ItP7 µ City Lot Size PM Owner's Na a c �l Address U Wr Phone ,f. - ' Contractor �� Address License No. Phone j TYPE OF WELL/PUMP: NEW WELL ❑. _ WELL REPLACEMENT ❑ DESTRUCTION. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ -=. DISTANCE TO NEAREST-.rSEPTI--TANK T'---= SEUVER=LIIVE5 "'" - DISPOSAL FLD:- ^" - PROP�LtNE r : ROUNDATION AGRICULTURE WELL OTHER WELL ; PITS/SUMPS INTENDED USEY �4YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial Lf Open Bottom Cl Manteca Dia. of Well Excavation .Dia. of Well Casing ❑ Domestic/Private E Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public F1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation qM�..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done .❑ Type of Pump H.P. State Work Done—r Well Destruction Well Diameter �� Sealing Material (top 50') -yr Depth,1/"L Filler Material (Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION'[ R_EPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is I� :' r available within 200 feet./ _ Installation will serve: Residence Commercial= Other IJV Number of living units: uM Number of bedrooms ? < ✓ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 1 Type/Mfg Capacity No. Compartments -PKG. TREATMENT PLT, ❑N 1 Method of Disposal Distance to nearest:# Well Foundation Property Line f T LEACHING LINE ❑ 1 No. & Length of lines Totai length/size FILTER BED. ❑ ! Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I II Depth Size Number SUMPS:, - R C1 Distance to nearest: y Well r -,Foundation•'�/ Y Property Line DISPOSAL PONDS ❑ " ' " 01 I hereby certify that I have 0Frepared this application and that the work will be done.in accordance with San Joaquin county ordinances, state laws, and rules and regulations of theSan Joaquin Local Health District. - "` ,. ;• Home owner or licensed agent's signature ce ifes the following: "I certify that in the performance of the work for which this permit is issued, t shall not m employ any person in such manner as to b ame subject 10 workman's compensation laws of California." Contractors hiring or sub contracting signature certifies the fall rn : "I ce 5ify that in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C ifor s T an mu for I qui c on . plate drawl reverse side. ' signed x Title: Facility Planner Data: 9/30/87 I ry +10 �lto FOR DEPARTMENT USE ONLY Application Accepted b i Date T Area r �y Pit or Grout Inspection by h Date Final Inspection b Date Additional Comments:110, 7 Yn ❑ Stk 466-6781 ❑ Lrodi 369-3621 ❑ Manteca 82 -7104 U 4fh Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT_NO. INFO + EH 13-24 IREV.i/8 51 EH 14-26 �3 d� + G� w[[[ i I�