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e APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT S 1601 E. HAZE T ON AVE., .STOCKTON, CA RECEIVED Telephone (209) 466-6781 1�LJr PERMIT EXPIRES VYEAR FROM DATE ISSUED SEP 24 1987 Iy�l (Complete in Triplicate) iNViRQNMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein r�$��g'1�1}� tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B952 for well/pump and the Rules and Regulations of the an oaquin Local Health District. Job Address 670x/ Al ss _= 4di/ d1e4 City Lot Size. f GLC„reaV V. d_ PM tL,NC►t'A/ c� } Owner's Name `Et/ / 2 L Address Ca."tPhone fF7 Contractor- � Address License Ivo. Phone 7 � TYPE OF WELL/PUMP: �,,,,N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION � ,., �`'�- SYSTEM REPAIR ❑ OTHER ❑ �DISTANCE TO NEAREST: SEPTIC TANK e' SEWER-LINES,--4+ - � ` DISPOSAL FLD-ArE • PROP. LINE 9J � �~ �"'� ' //`®�o FOUNDATION' 7�'r- AGRICULTURE WELL,.—� OTHER � 'WELL PITS/SUMPS o�� 4 INTEND D USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS”" F ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing I Domestic/Private Gravel Pack ❑ Tracy Type of'Casing��l/� Specifications' �e�0 1-1 Public n Other! iii Delta Depth of Grout Seal .<icx t Type of Grout 7e— I I Irrigation 6;?W_Approx. Depth �� I i Eastern Surface Seat Installed by Repair Work Done ❑ 'xc �Type of Pump- H.P._�. State Work Done 41,1e Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW dNSTALtATION I'1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ~ItfStnHe�i will serve: 'Residence ) Commercial_ Other r Number of"iiving units: umber of bedrooms Character of soil to a depth of-3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.KG. TREATMENT PLT. ❑ r I Method of Disposal Distance to nearest: Well Foundation Method LEACHING LINE ❑ No. & Length of lines Tota! length%size__ FILTER BED ❑ Distance to nearest: Well Foundation Property Line �' l SEEPAGE PITS I 1 Depth Size 40' .Number- '� SUMPS 171._Distance to nearest: Well Foundation a - - Property Line DISPOSAL PONDS 0 F "�""""'""'��`^� = -•• I hereby certify that t 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 noi-,' a s employ any person in such manner as to become subjeci 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 wemploy hich this permit is issued, I shall tion laws of California.:` persons subject to workman's compensa- tion The applicant must call for it r uired ins ctio Completo-drawin on`re4ar side. i Signed X Z^' Title: Date: n�z FO_ R SPAR M_ ENT USE ONLY.,d_ Application Accepted by9: - � �� ~ 1 } Rate 12Are x Pit or Grout inspection byDate `® Final Inspection by !6'C Date 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 IJ FEE AMOUNT DUE AMOUNT REMITTED INFO C RECEIVER BY DATE PERMI7•NO. EH 14-26 \ ' .� �7O �� (�9 �._ / s7 3 Wi 4