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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT R1EiVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP: 3:1988 f II PERMIT EXPIRES 1'YEAR'FROM DATE ISSUED r (Complete in Triplicate) 3 ,. ENVIRONMEN7.1 TAL HEALTH NMQQEI Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hldj> �bWVlrSpplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well/pump and the Rglles and Regulations of the San Joaquin Local Health District. ' t Job Address / Cityr Lot Size PM y [r tULI r rwrl®� �1.4/f �' Address Phone Owner's Namel��, �., g,� il Contractor ` ' f Address( N._�� '4lE C:`4,44'tLicense No. Phone 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ I 1. PUMP INSTALLATION ❑ " SYSTEM REPAIR El OTHER t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD: -= PROP r LINE"" FOUNDATION a IA.AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial !� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing It Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications ❑ Public " ❑ Other 11 Delta Depth of Grout Seal Type of Grout 13Irrigation --Approx. Depth D Eastern Surface Seal Installed by c�J Repair Work Done Type of Pump l H.P. State Work Dort Sealing Material Ito 50' ' Well Destruction ❑ Well Diameter 1= _ 9 P Depth "`� �' Filler Material'(Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION..❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation well serve: Residence— — Other Number of'living units' Numbe11I"Commercial of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg J` w1(S Capacity No. Compartments PKG. TREATMENT EATENT PLT. ❑ _ 5" Method of Disposal it f ~• Distance to nearest: Well Foundation Property Line LEACHING LINE ElNo. & Length of lines-AL -'" Total length/size I FILTER BED-1 ElDistance to�hearest: Well ^ Foundation Property Line SEEPAGE PITS ❑ Depth t^ Size Number SUMPS ❑ Distance_ to nearest: Well Foundation Property Line F DISPOSAL PONDS ❑ w a I 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 Lo61 Health District. I 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 be66me 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 persons subject to workman's compensa- tion laws of',California." _ The applicant must call for all require spections. Complete drawing on reverse side. Signed Title:_ �d�� Date: ;I I" FOR DEPARTMENT USE ONLY Application'Accepted by �' Date �- Atea �) II Pit or Grout Inspection by Date Final Inspection by Additional Comments: LlStk 466-6781 El Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 Applicant-'Return all copies to: Environmental Health Permit/Services M1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`N0. + EH 1324 IA EV.1/851 EH 14-26 II - it .. v. .. .