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APPLICATION FOR PERMIT SAN JOAQUIN.LOCAL HEALTH DISTRICT # 1601 E. HAZELTON AVE. T S OCKTON, CA ri Telephone (209) 466-6781 ,_ AUG 10 19$7 § f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVI tDO��{MITE/NTA�L�►�HEA.LTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w�r�lrif8f�fr5 tl n6eI Pill application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address JAl DLt1 Y City t Size Ply/ j Owner's Name �io4 rQ fr � S � Address 17221 ✓V. Phone 333 r 86 "71 p � t/ Contractor �/ J� Address X? `�y�0 �/Svy-e pVN License No. 9611 s/ ?�ryone 3 y E3�f^'Y/ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ } DISTANCE TO NEAREST: SEPTIC TANK /aD SEWER LINES DISPOSAL FLD. /00 PROP. LINE FOUNDATION = 'ZS --AGRICULTURE WELL-:f!!f' OTHER WELL; _-PITS/SUMPS1.;�C? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial 0. Battvm ❑ Manteca Dia. of Well Excavation ! f(� _p Dia. of Well Casing %,1 F 5 Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing_ coQ Specifications /Qf A ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �D ❑ Irrigation p Type of Grout gs� g _-.__.Approx. Depth El Surface Seal Installed by , } Repair Work Done ❑ Type of Pump- H.P. State Work Done i Well Destruction '❑_' Well Diameter` Sealing Material (top 501 Depth Filler Material (Below 501 J TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publiclsewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms y 'Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 ' PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation. Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 171Depth 4 Size Number 4 SUMPS ❑ Distance to nearest: Well Foundation Property Line r 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, sate 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Califomia."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." I f I The:pp on reverse side. Signd Itis: -. � —r Date: 0 �`1 { FOR DEPARTMENT USE ONLY .q } Application Accepted byDate a I �/ Area Pit or Grout Inspection by Date Final Inspection by�'� Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i. INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMiT'N0. + EH 13-24 iREV.t/85] EH 14-28