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APPLICATION FOR PERMIT y0 SAN JOAQUIN LOCAL HEALTH DISTRICT ;;;yyy C� �/ rt WWW F� 1601 E. NAZE' �/�TON AVE., STOCKTON, CA ;,� C Telephone (209) 466-6781 2 4 1988 PERMIT EXPIRES 4'YEAR FROM DATE ISSUED (Complete in Triplicate) L=i�'ti';t';="*`_ 3fh "'- 'L'•'` PEI�11,Ai r �iitfl� l J 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r-? �-eo S Cl.f t-t.(_'7-,E �� „ Z-4I`---tCo—Ley Job Address dy a` �''of A , � City �-G Lot Size ( PM Owner's Name f 42OR d4 Address -Af DI J& /i(!4- Phone �YO� Conlractor �Lrltt✓pr- Address 3 ,` 4r' License No. NZ Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER E �V DISTANCE TO NEAREST: SEPTIC TANK ��_ SEWER LINES DISPOSAL FLEA C PROP. LINE FOUNDATION AGRICULTURE WELOVMZ�r?OTHER WELL 'L�. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA Cf f/ ❑jndustrial El Open Bottom LI Manteca Dia. of Well Excavat' n Dia. of Well Casing �+�y Domestic/Private Gravel Pack 1196 racy Type of Casing �G• Specifications 4 Q1 M Public F] Other 171 Delta Depth of Grout Seal Lay/ Type of Grout flof `' 1� I I Irrigation "f� �1 ._Approx. Depth t I Eastern Surface Sea! Installed by ��/ '#�• _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 i DESTRUCTION i I (No septic system permitted if public sewer is 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 1 I Depth Size ..Number 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 Di§trict. 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 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,l shall employ persons subject to workman's compensa- tion laws of California." The applicant 7152II for all r qui i pections. Complete drawing on ravfe�a sides. Signed X Title: !/ rz��r _ Date: C ~�� FOR DEPARTMENT USE ONLY r/ IV Application Accepted by Date [U Area Pit or Grout Inspection by Date o�$'�� Final Inspection by Date Additional Comments: 171 Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 INFO FEEA�MO�UNT DUE AMOUNT REMITTED CASH RECEIVED BY T rDATE PERMIN0. •.EEH 3-24 H11-28tHEV.tiKsl !Q ��11 . i,.� "�j++'� 1�*