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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D aw 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 2 1987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTCCA��L��HEAcCLTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heRiEWXA.4TM5�Wph�ation 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. Job Address �L,Q�d !" �/f _ City Lot Size PM Owner's NameiQaWMISe Address Phone u36 — 6 7 C93� ! Contractor License No.=1-2F Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK 100 1 -''SEV1fER:LINES DISPOSAL FLD. PROP. LINE \ FOUNDATION S";'�-`;AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA_GONSTRUCTION SPECIFICATIONS ❑� Industrial ❑�Open Bottom Q Man pi of Well Excavation_f.i� Dia. of Well Casing "V *'pomestic/Privatend� ? Gravel Pack e'rracy Type of Casing PL- ycw— ff,26 _ Specifications Cl Public ❑ Other ❑ Delta_ Depth of Grout Seal AW JF-71— Type of Grout ❑ Irrigation /Jc1_.wpprox.. pepth O Eastern Surface Seal !ns#ailed by ! Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter k Zk SealingiMaterial (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION M REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 available within 200 feet.) Ins ta serye: Residence_ Commerttral_ Other ' -«..�.,,.-..........,..�...._.r.... ice- , Number of living units: .bar of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg W' - �'�' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation roperty Line i� S ✓� LEACHING-LINE—E9---No-�,&-l:ehgth ofiines, Total length/size a r FILTER BED ❑ Distance to nearest;'i'�;f1lUpII Foundation Property Line i SEEPAGE FITS ❑ Depth Size x Number Z:;❑ SUMPS ' i.r, :p -�€tDistance t&nearest: Well • , �,;fFoundation Property Line € DISPOSA6PONDS ❑ I hereby certify that I have prepared this pplication 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 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." t The applicantRWs all r all?,gqiro inspections. Complete drawing on rev ise side. ! i Signed Title: Date4� ' _F DE ARTMENT US ONLY Application Accepted by Lid Date ! _Z`� `Area /05 Pit Grout nspection by Date Fina! Inspection by � Date ? Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MJnteca 823-7104 ❑ Tracy 835-6385 f 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 CK RECEIVED BY DATE PERMIT'NO. + EH 13.24 1REV.1/a s; / EH 14-26 . t