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APPLICATION FOR PERMIT r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " (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.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.r IAJob Address 223 S 0 . Wagner` citySt 0 C k t 0 f1 Lot Size PM I1 bwner's Name Oliver E'. F*1 11 a Address 223 SO-. Wagner .S Phone – f� I Contractor t: Address License No. Phone TYPE OF WELL/PUMP: NEW WE ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION SYSTEM REPAIROTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL Z OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AR CONSTfiIdCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca ia. f Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack ❑ Tracy yp f Casing Specifications w 171 Public n Other F1 Delta Depth o out Seal Type of Grout I I Irrigation _.-Approx. Depth ( I Easte Surface Seal I Iled by Repair Work Done ❑ Type of Pump H,P, -State Work Done _ Ii Well Destruction ❑ Well Diameter Sealing Material (top 501 01 Depth 1 Filler Material 1Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION (-I REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is -available within 200 feet.) . Installation will serve: Residence! Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 Meet Water table depth ` SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments CID PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line „ SEEPAGE PITS I I Depth +, Size Number SUMPS E_1 Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this applicatioh 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,_I^shall.not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractin=g 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 t c or all re fired inspections. Complete drawing on reverse side. Signed x r'iw. Title: C W n Date: March 2 9 , 1988 FOR DEPARTMENT USE ONLY Application Accepted by { Date Area Pit or Grout Inspection by * Date Final Inspection by f, � DateG Additional Comments: (0 ❑ Stk- 466-6781 ❑ LoW 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 I (NEED AMOUNT DUE.1 AMOUNT REMITTED �H RECEIVED BY DATE PERMIT'NO. +.E13-24(RFV.tins) EH 11-28