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,E APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Q € o 466-6781 Telephone �209 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 1 � 1987 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the,work fi1RWI&Cf'I 6 W"Uf s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules andp"q?A"*E9osquin Local Health'District. 1 Job Address fd�1O t/, City Lot Size PM Owner's Name Address Ito 0 0 L.lJ- llft�rr r a-43 Phone Contractor ,/ Address / of `'*�-C �ILJ't , License No/ Pito TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' r F01rlIa A 1 6fiF AGRICULTUR1;-WEtL = ## }1`tlVELt .PIT4fSkIMPS =t .,. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRJCTIONI SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Wed Casing 2'Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications rl 171 Public Fl Other ' Cl Delta Depth of-Grout Seal Type'of Grout__. _ I I Irrigation --Approx. Denth . I I Eastern rface Seat Installed by Repair Work Done Cl- Type of Pump r- H.P. 1 State Work Done RAZE � « Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Melow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I _DESTRUCTION I I INa sept system permitted if public sewer is available within 200 feet.) -Installation will serve: Residence __ `Commercial Other Number of living uniWs :Number of bedrooms Character of soil to a depth of 3 feet Water table depth- SEPTIC TANK' O Type/Mfg Capacity No. Compartments PKG.>TREATMENT PLT.110 : i Method of Disposal Distance to nearest: Welt Foundation Property,Line LEACHING LINE ❑ Nor:&Length of tines Total.length/size FILTER BED` ❑ `'Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ I herebq certify that I have jzr`epared this appticet�ort i►nd that the work will be dor*at ac Yt+I t I ' ar rancea,state laws,and rules and regulations of the San Joaquin Local Health District. Home owner or rtcensed agent's signature certifies the following: "I certify that in the performance of the work for which the perrrut is issued,1$had 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:"1 certify that in the performance of the work for which this permit is issued,I shad orploy persons subject to workman's compensa- tion taws of California." The applicant mu adf r all requir '.inspectionomplete drawing on re side. A Signed X � �"7itfe. Date: KZ FOR DEPARTMENT USE ONLY Application Accepted,by �f�i DateO` Area Pit or Grout Inspection by Date Final Inspection by Date 6 y1 Additional Comments: )w A ZU LP- ❑ 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 85201 FEE AMOUNT DUE AMOU REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH ♦EN 1324(REV.rills) EH 14.26