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/7d3 �3 f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL-HEALTH DISTRICT ��c►7y 1601 E. HAZELTON AVE., STOCKTON, CA Telep hone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 31 1988 (Complete in Triplicate) nn Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worE 9e iR UAthiHFppU1ir,is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anF PFWffY5VRVKa8 Joaquin Local Health District. f f, Job Address City Lot Size PM p D- J ! r C L V /1��L+ �d ! Phone 3 3 D- 150, Owner's Nam Address s Contractor r� Address d —License No/(_��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ` PUMP INSTALLATION ❑ `+ SYSTEM REPAIR ❑ OTHER ❑ t 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well"Excavation Dia. of Well Casing U;i'Domestic/Private ❑ Gravel Pack (`Tracy Type of Casing r Specifications (1 Public ❑ Other t ❑ Delta' Depth of Grout Seal Type of Grout — I I Irrigation _.Approx. D�e th �l1—Eastern r Suri a Seal Installed by s Repair Work Done V Type of Pump � H.P. r f State Work Done Well Destruction ❑ Well Diameter Sealing'Mate`ial (top"501 a Depth Filler Material (Below 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l 1 (No septic system permitted if public sewer is m i; "` P available within 200 feet.) f 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 epth-x-SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ y Method of Disposal Distance to nearest: Well Foundation %!Property.Line r � Y t LEACHING LINE ❑ No. a Length of lines Totat length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS FI Depth w" Size Number SUMPS L] 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 I rules and regulations of the San Joaquin Local Health Diltrict. ,r 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, 1 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 shall employ persons subject to workman's compensa- tion laws of California." P The applicant ust ca for all required.inspecti ns. Complete drawing o reverse side. -2 Signed X itle: Date: / FOR 0 RTMENT USE ONLY i Application Accepted by . Date / Area Pit or Grout Inspection by Date Final Inspection by Date °t Additional Comments: `y ❑ Stk 465-6781 ❑ Lodi 369-3621 ❑ Manteca" 623-7104 ❑ Tracy 935=6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.-Hazelton Ave., P.O. Box 2049, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK4 RECEIVED BY DATE PERMIT'NO. INFO CASH ..EH 13-241REV.rik51 / EH 14-28 •J - r