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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE ISSUED MAY 18 1987 (Complete in Triplicate) ENVIROMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work]ROR�Jf�� plication 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 e1�an Joaquin Local Health District. 1 Job Address City `! Lot Size PM Owner's Name ye� ,� Ad zUFki4 Address �� / �-� Phone – is Contractor's Name i �_rA License No. Phone TYPE OF WELL/PUMP: NEW WEI L ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONS SYSTEM REPAIR.{ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 4:1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,JR�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. depth� /❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. / 410 State Work Done �C Well Destruction ❑ Well Diameter _ Sealing Material (top 501 Depth /dD ' - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r k . 1.,, 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 ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISP013AL PONDS ❑ 1 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 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 ch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature certifies the followi 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 Califo 1 The applicant m I r all qui inspections. Complete drawing on reverse 'de. Signed "" — Title: Date: DEPARTMENT USIrONLY r– Application Accepted by QL4 =,s�Fl�Ck ^� �7 Date " G�0 v Area Pit or Grout Inspection by Date Final Inspection J Date �✓ C r " Additional Comments: W ❑ 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 INFO OUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE �-A PERMIT"NO. + EH 1324[REV.10183) EH 1426