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I, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA JUN 151994 I� Telephone (209) 466-6781 ( PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN LOCAL Il HEALTH DISTRICT, {Complete in Triplicate} 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.543 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _� '� � 4,"tAlcity 1 —&s9 PM r-- / ofs Owner's Name I� ddress ��u �i Phone Contractor's Name II se No. L Phone ^A6 2 TYPE OF,WELL/PUMP: a NEW WELL ❑�. WELL REPLACEMENT ❑1 DESTRUCTION ❑PUMP INSTALLATION.!/ SYSTEM REPAIR.&-/ —OTHER EJ I 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 ❑❑ Indtrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing I ome56c/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout U) ❑ Irrigation 1'Approx. Depth ❑ Eastern Surface Seal Installed by W I Repair Work Done (Typert of Pump H.P, ,f State Work Done I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 I Depth Filler Material (Below 601 — i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION O (No septic system permitted if public sewer is 11 available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet:__ Water table depth -� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ li Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C Depth Size Number SUMPS _ C Distance to..nearest: Well' Foundation=- —•Property Line, DISPOSAL PONDS C !� 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 licen nt'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 para in such liner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the f wing: "I ce that in the performance the work f which this permit is issued,I shall employ persons subject to workman's compensa- tion laws o ailfo ' The appli nt mus or 1 ieq d' omplete d wing on rave side. i Signed Title: Date: FOR DEPARTMENT USE ONLY G� ` Application Accepted by1'M c rll r Date Ll Area I 8 r Pit or Grout Inspection by Date Final Inspection by y� Date Additional Comments: ❑ Stk 4664781 ❑ Lodi ,369-3621 ❑ Manteca 823-7104 C Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 II FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT NO. INFO CASH +EH 11-26(REV.10/83) s �� 6L.i r�•