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r APPLICATION FOR PERMIT PTCEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZEL T ON AVE., STOCKTON, CA J U N 2 0 1984 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) 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. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I City Owner's Lot Size PM Job Address Address " -- Phone Owner's Name Q�3,4 c� (�Z Phone Contractor ddress l(o Lzicense No. I' TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT ❑ DESTRUCTION 1-1 PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial EJ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing rT a of Casing Specifications ❑ Domestic/Private CI Gravel Pack El Tracy YP 9 Fl Public Cl Other 17 Delta Depth of Grout Seal Type of Grout --- I I Irrigation f� _.Approx.lDepth I l Eastern Surface Seal Installed by Repair Work Done �` Type of Pump H. State Work Done � Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -,I Filler Material (Below 50'1 -- TY E OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) % t x . k Installation will serve: Residence Commercial— Other u Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments °e Method of Disposal PKG. TREATMENT PLT. ❑ ' Distance to nearest: Well Foundation Property Line ' - Total.length/size LEACHING LINE ❑ Na. & Length of lines :.1 i Property Line FILTER BEO ❑ :'bistance-,to nearest: Well Foundation � rw I k SEEPAGE PITS I 1 DepthSize Number LSUMPS Ll 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 lawsJan 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, l shall no i 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." The applicant must c for all req Irt inspections. Complete drawing on reverse side. p Si ned X ' Title:r, Date: g , �. DEPARTMENT USE ONLY Application Accepted by Date "' Area Pit or Grout Inspection by I Date Final Inspection by Date 7 �v 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 I FEE AMOUNT DUE AMOUNT REMITTED ASH91 RECEIVED 8Y DATE PERMIT NO. +.EH 13241REV.iinSY EH 14-N '.1r