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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA OCT 2 9 1986 i Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED PU$Ll;��E�A�TH SOR�!'.1_r a. (Complete in Triplicate) ENVIRONMENTAL HEALT8 Divi610N 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 my Ordinance No.549 f r sewage for No. 1862 for wev.pump and the Rules and Regulations of the San Joaquin Local Health District. ��-7W 2-6 LN 9 ff,-rA J" , ,f':k` 51n;aQW 1-, w. ,+� VP,re 4 ; � City PM t Job Address Lot Size Owner's Name �� Q Addres Q TI�,Phone4 ContractorContractorlivL I Addresaawrcens�No. ane Y i TYPE OF WELL/PUMP: NEW WELLEZ WELL,REPLACEMENT ElDESTRUCTION ❑ 5 PUMP INSTALLATION ❑A {� Y .0 SYSTEM REPAIR ❑ OTHER { gY�'tn+ r DISTANCE TO NEAREST: SEPTIC TANK �*>50 SEWER LINES 7� DISPOSAL FLD. PROP. LINE n' FOUNDATION > AGRICULTURE WELL ._-f OTHER WELL PITSISUMPS 70 r f tQ iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tat r ❑ industrial ❑JOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k3� 3 ❑ Domestic/Private L+�1 Gravel Pack ❑ Tracy Type of Casing ``,,P4 { Specifications �s I'1 Public ❑ Ojt�er ❑ Delta Depth of�,,,tSeal tL/Y"� ?+ TYpe of Grout 1 I I Irrigation 25�f4pprox. Depth 1.1 Eastern x�tllrrtstalled by ' Repair Work Done ❑ Type of Pump l/ H,P. State ork Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 { Depth 94J. a �T Filler Material IBelow , — TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other > Number of living units: Number of bedrooms G 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 ,y `1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 6- SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line i 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 DoMrict. 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 (` t employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature L r 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 applic all I required inspections. Complete drawing on reverse side. f �+ +;1 Signed X Title: �� M a nt Date: ( 25 C 0 117 OR DEPARTMENT U ONLY Application Accepted by Date 9 ¢r� Area Pit or ro Inspection by Date rJ 6 / O Final Inspection by "� Date(� U F Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ racy 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 CK RECEIVED BY DATE PERMIT ND. I + EH EH 14-24(REV.t i H 51