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' n Y APPLICATION FOR PERMIT IDAYMENT 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 'itgGEIVED 1601 E. HAZELTON AVE., S T OCKTON, CA g 198$ Telephone (2091 /16 8 - 34.7 o JUL PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH JEWRONMENTAL HEAL (Complete in Triplicate) PERMITISERVICES 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 Counry Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.-) istt�rriict. - C2��cr� Job Address L1,57t — w' , � � � City Lot Size F'M Owner's Name .lam r" Z r, Address ! 0 ` 1`/ll(� r ' C Phone e, 5;— 3 13 Contractor ✓_ D `'t f?�!'�(n} L?` Address �1 . it e � Lr Licanse No. J 2 z Phone TYPE OF WELL/PUMP: NEW WELL JR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ¢✓" Dia. of Well Casing F! Domestic I Private Ll Gravel Pack KTracy Type of Casing Serf' 40 ve Specifications Ls Public Other #3 SA14b I I Delta Depth of Grout Seal 2-"ll 5i •d � Type of Grnur N—''fT � C1 Irnganon _Approx. Depth I 1 Eastern Surface Seal Installed by,A,fru n f hler.ic% Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction Q Well Diameter Sealing Material (top 501 0 A4071,ill wello)" Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION 1 1 DESTRUCTION I I (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 feet: Water table depth ! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines 1p Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS. I 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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-contracting signil cartill the following. "I certify that in the performance of the work for which this permit is issued,I shall employ pe tons subject to workman's compensa- tion laws of California." The applicant m t II for all required ins tions. C rawing on reverse side. �F ✓�'f l Vt�" t Signed Title: ^ ri�Lf��--G�--Pl Data: j7 Q FOR DEPARTMENT E ONLY wQ Application Accepted byData Are Pit or Grout Inspection by < Date v/5 Final Inspection by - Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca SM-7104 ❑ Tracy 836-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk., CA W5201 FEE AMOUNT DUE AMOUNT REMITTED Cll =RECEIVED EIVED BY DATE PEAMIT'NO. INFO • 1H 13-24 IREV.t,14 50