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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J° Telephone (209) 466-6781 � l !PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP 1987 t' (Complete in Triplicate) R EIVVIROMEI� f-��,,f . Application is heieby made to.the San Joaquin Local Health District for a permit to construct and/or install the work he+�ila� € i f tdtlt7n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu Joaquin - Local Health District. e . Job Address AL 1 City, Lot Size PM Owner's Name Address r ,U 7 £ f' `-111 Phone 3 J — 3r i ContractoreL1 L-_[-"� 1'Yt .S Address + a5fti ense No. G toa 3-7J Phone TYPE OF WELL/PUMP:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ +� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - _ —:FOUNDATION"----' ' •AGRICULTURE=WELL OT-HER.-WELL--_�1 - -LPITS/SUMPS'_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing 1 Specifications i`1 Public ❑ Other .�, t F1 Delta Depth of Grout Seal I i Type of Grout _ n ' I 1 Irrigation _.Approx. Depttl I I Eastern ' .Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done ._ Well Destruction ❑ Well Diameter Sealing Material [top 501 m Depth Filler Material IBelow 501 a TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is f i 1 available within 200 feet.) Installation will serve: Residence—1.Commercial_ Other Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 PKG, TREATMENT PLT. ❑ j Method of Disposal j Distance,to nearest: -.y Well Foundation h'` Property Line s LEACHING LINE ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation I Property Line E SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation 'Property Line DISPOSAL,PONDS P ❑ 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 taws 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. st cal toc all requ d inspecti ns- Complete drawing on reverse side. ; t Signed X itle: '�-✓ _ . , , _ ... Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area 1 P Pit or Grout Inspection by Date Final Inspection by,5+ Date7nel Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health.Permit/Services 1601 E'.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4 LL FEE f INFO' AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMI'r'NO. low + EH 13-24(REV.t i a s1 EH 14-2e 3