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APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT - t�y 1601 E. HAZEL T ON AVE., STOCKTON, CAR 2r� , r Telephone {209} 466-6781 `irVV/Rp N �,rr�,��C �,P�-. � �-dw PERMIT EXPIRES 1'YEAR FROM DATE ISSUED PERM r, ,; �fl r (Complete in Triplicate) a 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. Q (5 /fir ' Job Address 141N—RgE, Middle Of S P City Lot Size PM i Owner's NameEn QUEST0 Address Phone 17754 N. Hwy.88 , Contractor GOEHR l'NG PUMP Address License No. 309031 Phone_ TYPE OF WELL/PUMP: .5 NEWrWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1, PUMP INSTALLATION)OX SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - FOUNDATION, AG#iICULTURE.WEL_L^ OTFkER W.EL_L _PITS/SUMPS--_ r ? ? INTENDED USE i `TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ('l Public H Other F1 Delta Depth of Grout Seal Type of Grout_—_ I I Irrigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump TurbineH.P. 75 State Work Done nr Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I. I DESTRUCTION I I ('No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other y Number of living units: Number of bedrooms " _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ` ' No. Compartments PKG. TREATMENT PLT. ❑ r. 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 r ' i SEEPAGE PITS l I 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 rules and regulations of the San Joaquin Local Health DiMrict. Home owner or licensed ages' ignature 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 ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " y 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 Caliform . The applicant mu or all re i ed ins ctions. Complete drawing on rev r e. Signed X Title: Date: o/'//' FOR DEPARTMENT USE ONLY X Application Accepted by Date ' G1 Area IV Pit or Grout Inspection by Date Final Inspection by eo.,LM4 Date _ Additional Comments: :!r—k. ❑ Stk 466.6781 �❑ Lodi 369-3621 ❑ Monte 823-7104 ❑ Tracy 835-6385 S J�^- r Applicant - Return all copies t Environmental Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, Stk., CA 95201 l.tJZ �- ,-l *ej_wo,�- FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH E +.EH13-24(REV.i i H s) 7 EH 11-28 y