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Z APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 11'YEAR FROM DATE ISSUED (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health Districctt.. Job Address r +L ��/ � "� City rte" Lot Size PM Owner's Name �v! ,V1v � tiv'• Address L� Phone Z I • `may - _ I �]/' �j � �/ /+� Contractor �� I J L Addtes "f 7- . (llLu�l 15L-s ense N0,1�3 5 t�Urf TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT C7 DESTRUCTION ❑ PUMP'INSTALLATION 1�1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC.TANK, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excav tign Dia. of Well Casing Zr1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'Ju') 40 Specifications , y FI PublicOther"lo Cl Delta Depth of Grout Seal ��r Type of Grout er I I Irrigation _..Approx.•Depth I I Eastern Surface Seal Installed by �/ �T�� Repair Work Done ❑ Type of Pump H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l I DESTRUCTION l I INo septic system permitted if public sewer is Iv 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 CapacityCompartments PKG. TREATMENT PLT. ❑ t r s 1-.. D eI- Distance to nearest: Well Foundation one LEACHING LINE ❑ Noa& Length of linesTotal length/ 7 '1989 FILTER BED ❑ Distance to nearest: Well Foundation Property Line I. ENV1R01',,V1r�ITAi. -;r LTH SEEPAGE PITS i I Depth Size Number 2 i SERVICES SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ !I 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, an 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: "=1req the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of C n-@ The applicant s d inspections. Complete drawing an reverse side. ff,�} Signed X Title: U V L'-bc-4&kf Date: FOR DEP NT S NLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by �m _ Date - iI 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. Bax 2009, Stk., CA 95201FEE 5 INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMM NO. a.EH 13-24(REV.I/H 5) EH 11-285