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APPLICATION FOR PERMITA� �I SAN JOAQUIN LOCAL HEALTH DISTRICT IE P � 1601 E. HAZELTON AVE., STOCKTON, CA F f q Telephone (209) 466-6781 �( v PERMIT EXPIRES 'I"YEAR FROM DATE ISSUED CA M�� HtiA��H JUN 2 Q �- ++�TT��yy (Complete in Triplicate) eA,4w, �1�15�R\11C?5 A i�{i ww"84AWAan Joaquin Local Health District for a permit to construct and/or install the work Herein described'"'This application is m� p j EAy f@E$oaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local �eF�H r rrct. rlW IV�, /, �� G?9 �T City Job Address ,1WAe1U� Lot Size_ago/X, 5?e PM J' Owner's Name C'aG✓YO�� 1� / Address //7 W. VA4V_-7-' Contractor f' /YD Address _5AW1114V T ,CA 4546/- License No.G'S�i�Mf.3Phone_9-71 1 TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION ❑ l� G PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IR y— DISTANCE TO NEAREST: SEPTIC TANK /fX�� SEWER LINES _ SQA DISPOSAL FLD.__J��_._ PROP, LINE N1"�� FOUNDATION Nfl� AGRICULTURE WELL.�� OTHER WELL PITS/SUMPS �g INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation S I!'I Dia. of Well Casing Z7 /L— ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SGW 'STD FX-1 Specifications R Public 0 '0' Q�Cl Delta Depth of Grout Seal 0S� Type of Grout I I Irrigation �.Approx. Depth Eastern Surface Seal Installed by <;� _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION l I OESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms t 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 f� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ['I Depth Size Number i SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Ip EE I hereby certify that_) Eiave prepared iFiis'application'and that the work wdl be done n accordance with'San Joaq n county ordinances State IaT ws a d 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 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 st all for al®r .,d i ction lete drawing on reverse side. Signed >FfTitle:__��CS/ Date: `� l oe" �, A tz,.- — - FOR DEPARTMENT USE ONLY Application Accepted by MAe 1k Date 4 Area Pit or Grout Inspection by Date? of_8__g� Final Inspection by Date Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 C] 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 + EH1t4-28 3-241REV EH ,1/85) - / I .�