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:. APPLICATION FOR PERMIT P;a= E i ' SAN JOAQUIN LOCAL HEALTH DISTRICT APR 2 1991 1601-E. HAZEL ION AVE., STOCKTON, CA ENVIRONMENTAL HEALTH Telephone {209) 466-6781 . . , - I PERM PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. ? " Job Address City7;Z4CSize PM Owner's Name MP Address SAMUET 1-L Phone Contractor ess se No. Phon TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA�}}N�� SYSTEM REPAIR C1OTHER CJ DISTANCE TO NEAREST: SEPTIC TANK .7[ SEWER LINES DISPOSAL FL _1-PROP.-LINE FOUNDATION' AGRICULTURE WELL OTHER WELL,AM PITS7SUNIAS— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/PrivateGravel Pack `�Tracy Type of Casing 5`TT�L Specifications ❑ Public Othgr ElDelta Depth of Grout Seal —�! ' l _- Type of Grout y*krigation pprox. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction —17 , 1 Well Diameter l ~ � Sealing Material (top 501 Depth. . -Filler- -- . n-Filler Material IBelow 501 � m TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) ` Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms t' Water table de th h Character of soil to a depth of 3 feet: f p SEPTIC TANK ❑ Type/-Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well P Foundation Property Line L, f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number € SUMPS ❑ Distance to nearest: Well Foundation Property Line _ DISPOSAL PONDS 0 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. t. k Home owner or licensed agent's signature certifies the following: "1 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 applicFX a u c or requi inspections. Complete drawing on re �e side./_ -� Signed Title: Date: 3 FOR DEPARTMENT USE NLY ` 4 Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 4 ' Additional Comments: G f 4 cl - ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO �,/ CASH ,,AA��'' j �. .EH 13-24(REV.i/651 0 /_1 WJ `�^� ` 4v�� / 91—p) I t428 i