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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT � �� ►�6 �� ' 1601 E. HAZELTON AVE., STOCKTON, CA _ l Telephone (209) 4ss-6781 APR 18 1988 I PERMIT EXPIRES TYEAR FROM DATE ISSUED i (Complete in Triplicate) ENVIRIOME/NTAppL��//HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work hAM1X b-'TRiL(:4Aication 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 ArJdress City Lot Size PM � �jjp a ( r Owner's Name 'ta�� / '�- Address f �l�- !S !t" r �Phone Contractor Address X License No. ?4is/ _Phone TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENr❑ DESTRUCTION ❑ PUMP INSTALLATION O SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP. LINE • I i FOUNDATION AGR ICU LTURE,WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION`SPLCIFiCi4T1QNS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing AWDomestic/Private ❑ Gravel Pack EI Tracy Type of Casing Specifications - r 1-1 Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Irrigation .-- .Approx_ Depth— I I Eastern Surface Seal Installed by _ Repair Work Done E] Type of Pump H-P. 1 State Work Done Well Destruction ❑ Well Diametei /1-r Sealing Material (top 50.1 r Depth Ods' Filler Material (Below 54') I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I tNo septic system permitted if public sewer is e available within 200 feet.) -Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms— Character edrooms Character of soil to a depth of 3 feet. Water table depth i SEPTIC TANK ❑ Type/Mfg.. Capacity No. Compartments PKG. TREATMENT PLT. D 1 Method of Disposal Distance to nearest: Well Foundation Property Line I 3 LEACHING LINE D No. & Length of lines Total length/size ` FILTER BED LJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1A Depth Size Number SUMPS Cl Oistance to nearest: #Well Foundation Property Line rDISPOSAL-PONDS= C3 .rr^- x i- ^�+. -•w R - • gnu+- - - I hereby caltify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, andp rules and regulations of the San.Joaquin Local Health District.- 6 Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person insuch nn as to'become subieet'to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I thet 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 o a I'SqUiod i tions. Complete-drawing on reverse We. ! Signed -. ..Title,_.---�+ nate: 46 OR DEPARTMENT USE LY �f Application Accepted by Date Area JA Pit or Grout Inspection by Date Final Inspection by ObA, Date- r Additionat Comments: ❑Stk 466.6781 ❑ Lodi 369-3611 ❑ Manteca 823-7144 0 Tracy 835-6385 _---- - - T Applicant- Return all copies to: Environmental Health PermitlServices.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' 1 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. j ♦EH 13.24 EH 14.26 IREY.lin51 r�+� J �$ 3 .