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r•1 r APPLICATION FOR PERMIT +.r " SAN JOAQUIN' � t LOCAL HEALTH DISTRICT FEB 13 9.87 1601 E. HAZELTON AVE., STOCKTON, CA " Telephone (209) 466-16* ENVIROMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED.7" VERMIT/SERVICES (Complete in Triplicate) la . . , ~^+• . 1. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is f. made in compliance with-San Joaquin County Ordinance No.549 for'sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District _ "► _ LL .. Job Address y� U City Lot Size PM y Owner's Name JU tzh!,b147 All-01 ef_ Address^ Phone �e { Contractor T (] U M Address �D ' D License,No.asi21� Phone TYPE OF WELL PUM . NEW WELL ❑ i WELL REPLACEMENT ❑ :DESTRUCTION ❑ PUMP INSTALLATION"V" � SYS7EAA REPAfR ❑ OTHER Ll T DISTANCE 70 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 D Manteca m Dia. of Well Excavation R r = Dia. of Well Casing l� Domestic/Private,. •❑-Gravel Pack ❑ Tracy Type of Casing Specifications " ❑ Public D Other ❑ Delta t°°i s-Depth of Grout Seal Type of Grout N El Irrigation —Approx. Depth ❑-Eastern - Surface Seal Installed by ' Repair Work Done ❑ Type of Pumpvj'�_ H.P. State Work Done Q6 �TnR Well Destruction �/ ❑ Well Diameter Sealjng Material (top 50') IZ3a Depth ' , Filler Material (Below 50') m TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is s available within 200 feet.) Installation will serve: Aesidence Commercial Other Number of living units: - Number of bedrooms i Character of soil to a depth of 3 feet: ; •;- T- — Water table depth SEPTIC TANK y k ❑ Type/Mfg Capacity No. Compartments PKG.,TREATMENT PLT. ❑ F � t Method of Disposal i I Distance to nearest: Well Foundation Property line LEACHING LINE ❑ No, &Length of lines Total length/size r FILTER BEA ❑ Distance to nearest: Well Foundation 'Property Line SEEPAGE PITS ❑ :.:Depth-- Size Number . _ �.w-- SUMPS - ❑ Distance to nearest: Well '2-:*` -« ' _Foundation Property Line DISPOSAL PONDS ❑ 4 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 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 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." '1 The applicant must call fo all required,Inspections. Complete drawing on reverse side. � d Signed _ Title: Date: ' > ! FOR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or Grout Inspection Date y [bate nal Inspection 7� 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 f FEECK AMOUNT DUE' AMOUNT REMITTED ' INFO CASH RECEIVED BY PATE PERMIT`N0._ + EH 13-24 VIEV. . 'EH 14-29 1%7` f L _