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.i APPLICATION FOR PERMIT PAYMEN t �. SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVES 1601 E. HAZEL T ON AVE., STOCKTON, CA I Telephone (209) 466-6781 im f"3 1990 PERMIT EXPIRES TYEAR FROM DATE ISSUEDcNVIRONMENTAL HEALTH (Complete in Triplicate) n�p�l��SERVIC S Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. his 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. a r. Job Address f Sr�e�d City Lot Size PMS rI' I \ G v` �Pe ,z oql �tCLletl`t Qy' A l Phone –oz�•�• Owner's Name Q 1 jw Address _�Qt� Contractor"14 `f�� 1*L�l�►L Address rr �� 4lkQ.,r Rd 944 License No.: z,27__ _Phone TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ k PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ ! DISTANCE TO NEAREST: SEPTIC TANK A90 SEWER LINES/M-� DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ell Casing t L3 Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of W iTj&Domestic/Private `"ravel Pack ❑ Tracy Type of Casing Specifications FI Public 1-1Otther ❑ Delta Depth of Grout Seal Type of Grout . I I Irrigation A.-Approx. Depth l I Eastern Surface Seal Installed by +^ �+� - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 W� TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIWADDITION l 3 DESTRUCTION l i (No septic system permitted if public sewer is W ql available within 200 feet.) € n Installation will serve: Residence_ Commercial— Other `' ! I !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 rn1 PKG. TREATMENT PLT. ❑ Method of Disposal % Distance to nearest. Well foundation Property Line .LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I ..Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ��t-hetebycertify-that-I'h�e prepared this applic`alion and that tthe work will'be'done in accordance with San Joaquin county ordinances, state-1-11s, � � 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X L{ I Title: Date: Q� Date: Ij �R DEPARTMENT USE ONLY Application Accepted by Date ( r Area Pit or Grout Inspection by II Date Final Inspection by Date li 4, D + l� rt I 1 Additional Comments: o EDcy Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tra835-6385 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 K RECEIVED BY DATE PERMIT"NO. +. INFO EH 13-2� v4)q`�O EH 14-28 /V r�pSG 3-L- ` [7 S