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APPLICATION FOR PERMIT �f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZELTO,N'+AVE., STOCKTON, CA ", . . ' - T"e-1ephone {2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. {Complete in Triplicate} JUL 1 1988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install themw rjt�ed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ru� r�i, /5 fsMgg ,Joaquin Local Health District. 'VV1l RVICES t r7 I O ' .z Job Address Cit t Size PM � �/ � 1r {?1 rAddres's Owner's Name r L } Phone f � Contractorress ® lql� ��License No. Phone t72 TYPE OF WELL/PUMP: NEW ELL ED / WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION [B/ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID.- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE 00 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I ❑ Domestic/Private 0 Gravel-Pack' ❑ Tracy" Type of Casing Specifications Cl Other 11 Public f�}., .1 ❑ Delta Depth of Grout Seal Type of Grout � ��w....-,.,,, I i Irrigation cl Approx. Detptl I ] stafn -Su a Seal Installed by _ Repair Work Done IBS Type of Pun'-, H.P. State Work Done Well Destruction ❑ -Well Diameter Sealing Material Itop 501sr"tDepth } Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLkTION_I,I REPAIR/ADDITION l I DESTRUCTION 11'INq.septic system permitted if public sewer is available within 200 feet,I Installation will serve: Residence_ Commercial x Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -Water table depth SEPTIC TANK' EJType Mfg 1 pacity No: Compartments PKG. TREATMENT PLT. ❑ , wry rt kk Method of Disposal Distance to nearest: ell' Foundation Property Line' ^-- � LEACHING LINE 0 No. & Length of lines /t, Total length/size. �. •--.:....,.,.�..,�---:gym„..a..:-.---•...- '�YYe11rw:�.. ..— —+�a+r� "^__ FILTER BED ❑ Distance to Weare ._ Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foun on Property Line �' l DISPOSAL PONDS ❑ r 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 regulation a San Joaquin Local Health District. Home owner or 'censed ag Wt'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 rson in such er as t ecome ject t6 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th oliowing: "1 c that in rf nce of the work for whic&thisrnmit is issued, I shall employ persons subject to workman's compensa- tion laws f alifon ia." The app cant f all re ons. Cete drawing on r Signed Title: Ae Date: (/p � FO . EPARTMENT USE ONLY i Application Accepted by Datey s Area Pk or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PPERMIT'NOJ. EM 13-24 EH1t25tREV. /x51 0-C—) Ft7-a. eER —m1