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E206 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT , 1601 E. HAZE T ON AVE., STOCKTON, CA ' �, Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSU D f � 199St (Complete in Triplicate) Application is hereby trade to the San Joaquin Local Health District for a permit to construct and/or install the,wofk herein.described-.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and theFR,fes and;Regulations of the San Joaquin Local Health District. i Job Address 4;w �+ City Lot Size Q PM owner's /�+�"� + Address Phone ` N Address � License Nal cv � Phone ` Contractor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION`$ SYSTEM REPAIR L1 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Y DISPOSAL FLO. PROP. LINE FOUNDATION / AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �G Type of Casin Sp€cifications ��+ r� �Domestic!Private �Gravel�Pack ❑ Tracy YP 9 „�,��y, I"1 Publico Other" n Delta Depth of Grout Seal o Type of Grout I I Irrigation `Y."Approx. Depth __I,I Eastern Surface Seal installed by - y; 'i H.P. _� State Work Done Repair Work Done ❑ Type of.Pump � Well Destr4tion ❑ Well Diameter Sealing Material ltop 50'l I r Depth', Filler Material {Below 50') STYPEpF SEPTIC WORK: NEW`Ih1STALLATION 1.1 REPAIRIADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residencei Commercial _ Other Number of living units: s M Niiinber of.bedrooms I Character of soil to a depth of-3-feet. -' i Water table depth C y SEPTIC TANK C3 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal �. Distance to nearest: Well Foundation Property Line r LEACHING LINE L] No. & Length of lines ! ? Total length/size FILTER BED [I- Distance to nearest: Well-_J Foundation` Property Line SEEPAGE PITS 1-11', Depth Size f Number SUMPS LlDistance to nearest: Well Foundationt� Property Line DISPOSAL PONDS EV I hereby certify that I have:preipared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 1 rules and regulations of the San Joaquin Local Health District. 1 ,1 11 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 manner as io 60618 a 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 peimit.is issued,'Itshall employ persons subject to workman's compensa- tion laws of California." x " The applicant c I fo all re inspections. mplete drawing on reverse side t..$ // (/ e I / / Signed X�_ tie: �"�_, Date: for FORT T ONLY / ., f // �Z.. Application Accepted by l Date Area Pit or Grout Inspection by Da., Final Inspection by Date I 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 CASH RECEIVED BY DATE PERMIT N0. INFO 1yl g- o +AH 13-241REV.1/85J EH 1426