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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 2 7 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. (Complete in Triplicate) ENVIRONMENTAL HEALTH ` r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h�rE"LU rk,%AWbpplication is made in compliance with'San Joaquin County Ordinance No. 549 for sewage or No- 1862 for well/pump and the Ruies and Regulations of the San Joaquin Local Health District. j Job AddressAAKM City Lot Size PM 4 Owner's Name Address a Phone II U2" -321 Contractorg)S.,Address se No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMPS INTENDED USE TYPE OF—WELL'— PROBLEM AREA—GONSTRUCT.ION SP.ECIEI.CAT.IONS ;- ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing "Domestic/Private C7 Gravel Pack ❑ Tracy Type of Casing - Specifications ❑ Public 11� Other ❑ Delta Depth of Grout Seal Type of Grout — I 1 Irrigation [---Approx. Depth l I Eastern Surface Seal Installed by 1 Repair Work one ❑ Type of Pump H.P. I�I� State Work Done Well Destruction EDV Well Diameter Sealing Material (top 50'I 1� / I&V 1� Depth Filler Material (Below 501 r TYPE OF SEPTIC WORK: INEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is M ji r available within 200 feet.) I :. j_. Installation Will serve: Residence_ Commercial _ Other Number oftiving units: i Number of bedrooms IF Character of soil to a depth of 3 feet: Water table depth 1I;f-N..a-.i 1z SEPTIC TANK ❑; 1TypWMfg Capacity No. Compartments ti � —' Method of Disposal TREATENT"PLT F PKG. . ❑ti ' e. f %'# Distance.to,,nearest: Well Foundation Property Line LEACHING LINE ❑t No. & Length ofllides Total length/size FILTER BED ❑: Distance to nearest: Well Foundation Property Line I {� 1 SEEPAGE9PIS I F Depthkf Size Number c SUMPS L Distance to nearest: Well Foundation Property Line ` DISPOSAL POND` ❑ r F hereby certii'y that I have prepared this1 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 ownevor 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,ih}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,l shall employ persons subject to workman's compensa- tion laws of California." " The applican'l m I I quire d ' c . Complete drawing on revers sL. ' Signed X ills: Date: . r FOR DEPARTMENT USE ONLY �7 » 4 t date �' U Area I O Application Accepted by .-...-.. 7 Pit or Grout inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ``� ❑'Manteca 1823-7104 ElTracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton kw.,_P.Q._Box,-2009, Stk.,CA 95201,_ FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMITNO. INFO CASH +.EH13-24 1REV.t/R W ` EH 14-26 �D