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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ga 1601 E-.WA2ELT-N;AVE:., STOCKTON, CA Telephone {209} 466-6781 S,,_ , 19 88 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED `" !i' ' (Complete in Triplicate) ENViREIN ENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heU4eEF$h TiVEgF_ AQWcation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. IB62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ag Job Address + LE City Lot Size PM ca s - Owner's Name ' S„ Address t L t1 f' �d _ Phone 0 r[� 1 L L Contract -` _ %0` Address X l 1 License No. ` kZ_3 Phone U v C TYPE OF WELL/PUMP: l NEW WELL ❑ WELL REPLACEMENT [I DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR leder OTHER ❑ DISTANCE TO NEAREST: SEPTIC ITANK S�WER LINES A .�DISPtjSAL FLD. PROP. LINE 1 FOUNDATION f AGRICCJL`TURE V1iElt---=-----OTHER.WELL_ _- _PlTS¢SUMPS INTENDED USE TYPE, F.WELLw.,,,,.._PROBLEM AREA CONSTRUCTION SPEC01GATIONS f \ ❑ Industrial ❑ Open Bottom LD Manteca Dia. of Well Excavation Dia. of Well Casing I Domestic/Private C1Gravel Pack LJTracy Type of Casing Specifications 1'1 Public �r F1.Other n Delta Depth of Grout Seal 4�+}1' f1 Type of Grout I dI d Irrigation E ; � Apprx. Dep I I Eastern Surfac Seal Installed by t _ Repair 1W; rl bone 'f�' Type of Pump _ H.P. State Work pane Well Destruction ❑ Well Diameter •- Sealing Material Itop 501 •�111>1f ,! �iti Depth ? Filler Material (Below 5Q'1 - — --- TYPE OF SEPTIC WORK: NEW INSTALLATION I:i REPAIR/ADDITION E I DESTRUCTION,I 1 INo septic system permitted if public sewer is �r = available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of Ledrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ;;��•X)❑�Not�&'Length o4 lines Total length/size FILTER BED a C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I. Depth Size Number SUMPS ❑; Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ l ; i I hereby certify th ve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regu ions of t San Joaquin Local Health District. Home owns or licensed ag is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r employ an person in such nner as to become sub' workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies t following:"I c ify that in th I rm ce d ha work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." l The ap ican u for all equi ro omplet drawing an re r id FIZ �� . Signed ; Title: ADate: k BE D PA ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Firiaf Inspection by Date r• _ U 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 FEE I INFO AMIOOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT�yND. + EH 13.24(REV.i f H 5) EH 14-26 C/_