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APPLICATION FOR PERMIT N JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA p p'Y M E N TD RECEIVE Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM DATE ISSUED NOV 13 1987 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall the work p°H "i mads in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R oaquin Loin Health District. Pa,+m l e.tJ ryL 5{-o trot 7t,tm l raa - I W L0,U h 1 n 9 f o n S{ • Navy 'Ori v_ I Job AddressP•r..t- di 121j,nr L _1n city 5±QCk12r3 Lot Sita 0140 0 r 1600 PM Owner's Name -Per+ Qi !ildfk' Address t0c201 W. 11)a.A1n1I:gfM4� gka39041S) Contractor Address 1 License No. Phone Ar 6 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. * PROP. LINE t00 Ii FOUNDATION AGRICULTURE WELL OTHER WELL � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial +� ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Selk Sp d" ❑ Public X Other ❑ Delta Depth of Grout Sea l 'I 3/ Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Minna H,P.-�-t State Work Done Well Destruction ❑ Well Diameter — 411 Sealing Material (top 50') Depth SO r Filler Material {Below 507 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) l Installation will serve: Residence_,.,_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 0. Water table deplJ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ( i PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Line ' SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 signature certifies the following:"I certify that in the performance of the work for which this permit Is issued,I OwIl employ persons subject to workman's compensa- tion laws of Catiforn' i The applicant m all for all requ' ns. Complete drawing on revs np de. Signed G Title: �';1/ �" Date: FO A IY r Application Accepted by Oats Area Pit or Grout Inspecti b Date Final Inspection�by ,,,,,, Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ cy 835-63j� Applicant• Return all copies to: Environmental Health Permlt/Services 1901 E. Hazelton Ave., P.O. Box 2009,�5tk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY INFO DATE PERMIT-NO. :EH 11211pEV.ties) �� , EH 14-20 7 `1 r1c X117