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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I;a7 r1 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209} 466-6781 J U N 3 1987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH FERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the h made e workerein described. This application is compliance with San Joaquin County Ordinance No.549 for sewag � Local Health District. e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Job Address Rp 4 City E&V Lot Size e PM Owner's Name y ke0 Address 4 Phone ¢I Contractor's Name S 4 License No. Phone - 757 I' TYPE OF WELL/PUMP: NEW WELL LJ —WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION,❑ OTHER ❑_ sSYSTEM REPAIR [7 DIS TO NEAREST: SEPTIC TANK V SEWER LINES DISPOSAL FLD. PROP. LINE v ^ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom [H Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private t ❑ Gravel Pack ❑ Tracy Type of.Casing F Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! I Irrigation Type of Grout ❑ \ ---Approx. ❑ Eastern Surface Seal Installed by N �' Repair Wotk Done ❑ Type of Pump H.P. State Work Done Well Destruction LJWell Diameter Sealing Material [top 50') � Depth Filler Material (Below 50') ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V Installation will serve; Residence--')e— available within 200 feet.)Commercial_ Other _. Number of living units: I Number of bedrooms q Character of soil to a depth of 3 feet: C la Water table depth SEPTIC TANK V -Type/Mfg t ('rkT -- . 3« Compartments Capacity �? � D Ga1 No. PKC. TREATMENT PLT,. L7 r -� - -Method of Disposal Distance to nearest: Well 50044 Foundation 10 F#. Property Line :ZO0 F 4J LEACHING LINE .,,No. & Length of lines - 19-5 Total length/size FILTER BED ❑ Distance to nearest: Wellp Property--��_ Foundation 100#�'�- Pro a Line 20 0 '�~� SEEPAGE PITS'. y Depth 15 ' Size— 14 70 �1. yA _ Number - SUMPS ❑ Distance to nearest: Well Foundation 106 Property Line 70Q 44 DISPOSAL PONDS ❑ I'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 District. Home owner or licerised 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 applicant must call for all required inspections. Complete drawing on reverse side. 1 Signed Title:_Cn^, S�VVr. a,v% Sunor, Date; �,�in.a 91 FO NT USE ONLY ' Application Accepted by Date 1"�'" Area Pit or Grout Inspection by Date Final Inspection by � Date _ I 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 S FEE OUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.10183) O 0I EH 1428