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- APPLICATION FOR PERMIT P,' 2 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ENVINUMENTAL HEALTH Telephone (209) 466-6781 FERMIT/SERVICES PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is helehy 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 District. Job Address t Mile E of Tully Rd. szl South Of- - city Linden Lot size PM Comstock Rd. (6956 Tu11y Rd. ) Owner's Na'meMr• MorandO Address 6956 Tully Rd., Linden Phone Contractor ./� /l � Address'. O. Box 64.tLiftd+en License No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONDELK PUMP INSTALLATION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i7 Public L7 Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H,P. State Work Done aha Indanr=r7 -he F*aUSe Well Destruction X Well Diameter 12" Sealing Material Itop 50'1 Well is located 12 * South Of Depth 120* Filler Material (Below 50') _ an aq. well now 1n use TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION'( I DESTRUCTION I I (No septic system permitted if public sewer is 4 available within 200 feet.) �l I Installation will serve: Residence Commercial_ Other 5►`} Number of living units: Number of bedrooms �.. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line�• LEACHING LINE ❑ No. & Length of lines Total length/size 1 r FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS I 1 Depth Size Numr � ' SUMPS Ll Distance to nearest: Well Foundation Property Line 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 District. 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, l shalt 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 parsons subject to workman's compensa- tion laws of California." The applic t must[Call f IIpt ired inspections. Complete drawing on reverse side. Signed X \� .Title: President Date: 1/28/88 FOR DE ARTMENT USE ONLY Application Accepted by Date zg "cid` Area 912 Pit or Grout Inspection by Date Final Inspection by Date 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. Box 2009, Stk., CA 95201 FEE INFO AMOUNT D/U}E AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO. + EK 13-24(REV.iiw 51 ?� EH 14-28 !!//