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n APPLICATION FOR PERMIT SAN JOAQUIN_LOCAL HEALTH DISTRICT D CEO o 1601 E. HAZEL I ON AVE., STOCKTON, CA S� Telephone (209) 466-6781 ., r �UPERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 10 1987 , (Complete in Triplicate) ENVIROMENTAL HEALTH wiryx� �P ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the rt 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 s Local Health District. Q d 1 Job Address 1 i7G1 SIP—r— City ,141st Size PM j �* �I p '1 Owner's Name r�f� � ci fi i Address 1723 1 JV Qdf�rr Phone �J 6(, 7 r Contractor ✓ ` ' Address7 1/87 �• _hiA� i"cense No. PI S/ Rhone 3 3�-1�34 TYPE OF WELL/PUMP: NEW WELL X7 WELL REPLACEMENT ❑ DESTRUCTION ❑ \. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /¢O SEWER LINES DISPOSAL FLD. /OQ PROP. LINE/4" r -� FOUNDATION. AGRICULTURE WELL OTHER WELC4 - :57 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� ❑ Industrial Opa� LJ Manteca Dia. of Well Excavation f Dia. of Well Casing ;<bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing - Specifications /0/4 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� Irrigation � p Type of Grout �S/E-- ❑ Irri g --Approx. Depth ❑ Eastern Surface Seal Installed by 0 Repair Work Done ❑ Type of Pump• H.P. State Work Done + Well Destruction 'D-' .Well Diameter". Sealing Material (top 50') ' ` Depth Filler Material (Below 501 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 F Number of living units: Number of bedrooms 1 !'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ff ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS' ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 M 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 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 applicant m II for all required in ctions. drawing on reverse side. Signed Date: �y 7 FOR DEPARTMENT USE ONLY q Application Accepted by Date �o l��/� Area 4` Pit or Grout Inspection by Date Final Inspection by Co, // Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 '❑ Tracy 83543M Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. + EH 124(REV.7/a 5) EH 14-2a& / 9t2 .(