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APPLICATION FOR PERMIT L HEALTH DISTRICT SAN JOA(lUIN LSCA .� 1601 E. HAZELTON AVE., STOCKTON, CA [A AY 18 1987 Telephone 12091 466-6781 - PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIROMENTAL HEALTH (Complete in Triplicate) FERMITAERVICES 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 woupump and the Rules and Regulations of the San Joaquin ti` Local Health Distric` .`R.s -t City LAA1 Lot Size PM Job Address 00 nC Phone �9 (1 �IL Ck3l c Owner's Name �� Address 49 Contractor G Address V� Wicense No. Phone �7 11 0 \ TYPE OF WE NEW WELL 71 . WELT. REPLACEMENT E] DESTRUCTION 171 PUMP INSTALLATION ❑ SYSTEM REPAIR JR 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 1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing V Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f`1 Public R Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth1 Eastern Surface Seal Installed by - Repair Work Done 171 Type of Pump � H.P. _� �� - State Work Donee Weil Destruction © Well Diameter Sealing Material {top 501 } Depth Filler Material {Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 DESTRUCTION 1 1 (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 y i Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. R Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number k SUMPS ❑ Distance to nearest: Well Foundation Property Line ..-".:;-,-DtSPOSAI PONDS=----[7 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 District. cert that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I 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 JA_ Title: I Date: c FO TMENT USE ONLY Application Accepted by Datd ""'-WT Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 83 6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE OUNT DUE AMOUNT REMITTED CASH RECEIVECK 0D BY DATE PERMIT'NO. L,OJ }�/+ EH 1324(REV.t/nS) Soo �5— � r�`� EH t4-28