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* SAN JOAQUIN LOCAL HEALTH DISTRICT rt APPLICATION FOR PERMIT ENVIRONMENTAL HEALTH DIVISION,, AN JOAQUIN LOCAL HEALTH DISTRICT P�AYMENTRMIT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 12. 1988 (Complete in Triplicate) tNVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo Qf Is application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 862 for well/pump and thg Rulets a'na' 'ti9Z1t1: e San Joagti Local Health District. �p �, �j pnl t� /}�jst 3d Job Address C , / J: V r?'J Di ,w _� City Lot L/c 3�v Lot Size PM Owner's Name ��l f/4? Address �J /_f• 4�1 iC LoIV6 � J_ C.��t Phone �� f/ ' Contractor d I'i9tL Address � License No.��Phona�z r? TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Zkf'— DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IDndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ORGravel Pack ❑ Tracy Type of Casing S�'tLL Specifications I"I Public `PI OtheqV09OW,7�''17 Delta Depth of Grout Seal -__ 16 �y 7lType of GGr��outt i_ k I I Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by &4ie! e!gHJ /o _ Repair Work Done ❑ Type of Pump f� H.P. �Z State Work Done Well Destruction ❑ Well Diameter Sealing Material /top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION i I (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 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 SEEPAGE PITS I 1 Depth Size Number SUMPS 0 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 Sart Joaquin Local Health Di1trict. Home owner or licensed agent's signature certifies the fallowing: "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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant mus ca r all require omplete drawing on rr�eyJ�rso ide. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted b Pp P Y Date � Area Pit or Grout Inspection by Date—l/2,_ Final Inspection byppDate Additional Comments: ��- G �r !/ 0'06& 11%,,C ❑ 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 /FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +. H 1$-2q/RFV.1/N 57 E EH 1426