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APPLICATION FOR PERMIT PAYW9NT SAN JOAQUIN LOCAL HEALTH DISTRICT REGEI V 9 D 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 APR 13 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED __ i (Complete in Triplicate) MOO ENTAL HEALTH PERMIT 5-. uI 1 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work fierem de cr�ed.qU 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. Job Address 219 SM MA L L U City 2t A Lot Size PM Owner's Nfa pr DAVE Per-LE Address 08Z CA Ll F0(Z1t)k ;.T. Phone LN ContractorSSt# OA LUAIG j =�C Address P,fl. OK 2 ( KOD AL'IcenseNo.�-ra��S�bj7 Phon42 Sys-gm TYPE OF WELL/PUMP: NEW WELL 19 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER VPIOIV►TVAZ L C4-4- DISTANCE TO NEAREST: SEPTIC TANK CoQ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial 1:1 Open Bottom ❑ Manteca Dia. of Well Excavation—` R fAu cif Dia. of Weli Casing 1 ❑ Domestic/Private l�Gravel Pack ❑ Tracy Type of Casing #�Ve- Specifications l'1 Public nOthpf CI Delta Depth of Grout Seal & � Type of Grout I I Irrigation .[_SApprox. Depth l I Eastern Surface Seal Installed byjQALL/.41r eAv _ Repair Work Done ❑ Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feeL1 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 i SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments 1 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 i SEEPAGE PITS I I Depth Size Number r 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 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 manneriis to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature j certifies the following: "I certify that in the performan of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of r ia.' The app/- ant c II for req ' ed inspections. C mplete drawing on reverse side. �] Signed X Title: I 's. Z _3� Lf Date: ! �� F EP NT USE ONLY Application Accepted by Date rea � i Pit or Grout Inspection by�� Date �v Final Inspection b Date Additional Comments: ❑ 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 RECEIVED BY DATE PERMIT'NO. INFO ,CASH • �.EH 13-24{REV-1/85) ��.o 130 �- EH 14-28 3:2� 6139