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APPLICATION.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT a 4 �! 1601 E. HAZEL T ON AVE.,--STOCKTON, CA Telephone (209) 466-6781 .� 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in.Triplicate? R GI 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 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. r �KLot Size PM Job Address (66-6 iEA°'4 i F�{ ��y��Ol�, � City X. Owner's Name � 2ss�sCA °1� � Y Address E AS4 Psi 1414 Phone Contractor S EAU Address 42c)o—C 7A A SAf. License No'7 _L2.pO_ Phone 3a TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION El E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ( ri ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V II ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout ❑ Irrigation _---Approx. Depth ❑ Eastern , Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 501 t (� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION fNo septic system permitted if public sewer is `. available within 200 feet.) l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: — Water table depth SEPTIC TANK ❑ Type/Mfg I capacity No. Compartments t 1 1 y Method of Disposal PKG. TREATMENT PLT. ❑ I .A + Distance to nearest: ' Well Foundation Property Line r -w- th/size LEACHING LINE ❑ No. & Length of lines Total len g FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distancetonearest: Well Foundation Property Line (III 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 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 i 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 appli a t ust c I f I required in Complete drawing on reverse side. �( �y X Signed Title: PzV��+ t S Date: "F�3` FOR DEPARTMENT USE ONLY �7 Application Accepted by Date �--� ( Area Pit or Grout Inspection by Date Final Inspection by L/""'�4 �n� ate 3 13 90 + Additional Comments: V_ ❑ 5tk .466 6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 w a s aK 5 r /Jo fccorc! p.c4c� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009; Stk., CA 95201 c I FEEAMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE PERMIT NO. INFO � EH 13-24 CRM 1/85) �1 EH 14-26 .... - '.