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!' APPLICATION FOR ERMIT SAN JOAQUIN LOCAL HEALTH,DISTRICT �i t, ,�1 Ir°"3 TLf 1601 E. HAZE I ON AVE., STOCKTON, CA Ifr �Jy .JtI. Telephone (209) 466-6781 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUf� 2 6 1989 (Complete in.Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hLTcation is { made in compliance with San Joaquin County Ordinance No. 549 for sewage of No.,1862 for welllpump and the Rules an e u! t�rsd+3�6N'lKre San Joaquin Local Health District. Job Address 7 0k,,-- 1 •P Ct_ City Lot Size PM Owner's Name Q -ph Q!•I?fYl ,Address �fi- Phone %- igkkk Contractor Address -1 License No. 3 d'1�Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK JM SEWER LINES DISPOSAL FLSPROP. LINE FOUNDATION ,AGRICULTURE.WELL_: . _OTHE WELL _PITS/SUMPS,,_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI fS ❑ Industrial ❑ pen Bottom ❑ anteca Dia- of Well Excav on Dia. of Well Casing -6 r_., g Domestic/Private ravel Pack Acy Type of Casing—' UG Specifications l 60' ,4 r-1 Public CJ Other FI Delta Depth of Grout Seal 1 6P(? Type of Grout v I i Irrigation _-Approx. Depth I Eastern Surface Seal Installed by + „ 1 Repair Work Done ❑ Type of Pump H.P. State Work Done , a Well Destruction ❑ Well Diameter Sealing Material (top 50') V Depth t Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION .I I DESTRUCTION I 1 (No septic system permitted if public sewer is • available within 200 feet.} Installation will serve:- Residence_ Commercial OtherL� 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 (�.h LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED LJ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS L) Distance to nearest: Well Foundation Property Line 1 xr,.:•IIISPOS,Ai PONfiiS,.w.w..C�s�-.�,-P-. ��+'= -- `' '�._ ' �,.7'�: �'"'t 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 Local Health Di1trict. .t 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 signature =F 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 applic mu call f all q red inspections. Complete drawing on verse side. Qr Signed Title: ", Date: FOR PARTMENT USE ONLY �r I Application Accepted by Date Area Pit or Grout Inspection by Date Fina! Inspection by 4 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ ant" 823-7104 ❑ racy 835-6385 Applicant-q�aturn all copies to: Environmental Health Permit/Services 1601 E. Haz ve., P.O. Box 2009, StJr �A 95201 INFO AMOUNT DUE a AMOUNT R MIT7ER CK A CASH RECEIVED BY DATE f ERMIT'NO. s r +.EHt3-24 IRE EH V.r i w 51 16-28 l r'- '