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APPLICATION FOR PERMIT Tj;J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J NOV 171987 Telephone (209) 466-6781 !� PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIROMENTAL HEALTH (Complete in Triplicate) FERMIT/SERVICES Application is haieby 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 County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San'Joaquin Local Health District. i + j. F .� /f/ rf 1 ,� Ci 0 tot Size PM ° Job Address _ Owner's Name Address /75' r Phone Z2 7 Contractor Address License N��_._Phone - TYPE OF WELL/PUMP: AW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLA I SYST!M/4REPAIR ❑ HER ❑ DISTANCE T�NEA EST P-Tif A W.. L XPROP"CiNE _>.. ,-FOU.HDATION.,-. AGRICU.LTU_RE WELL OTHER WELL PITS/SUMPS -, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Z&lf -` II. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Publi ❑ Other F1 Delta Depth of Grout Seal Type of Grout { i' rrigation �.Approx. Depth I Eastern Surface Seal Installed by - t Repair Work Done Type of Pump P.;�a State Work Done u a Well Destruction ell Diameter � Sealing Material (top 501 I,. I Depth # Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l l- REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is r available within 200 feet./ ; Installation will serve: Residence _ Commercial_ Other !I i t I Number of living units: Number of bedroorhs I Character of soil to a depth of 3 feet: Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments II PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.,&'--Length-of,;Iines r f Total length/size b 31 �, 7.1 W, ... FILTER BED ❑ DistaitceYto near; SEEPAGE Well Foundation Property Line ; SEEPAGE PITS I } Depth. 'SizeNumber ...... _ --- SUMPS Cl Distance to nearest: 'Well Foundation Property Line e 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. �j ,i 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 suEb-,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 m call for all quir Spec ns. Complete drawing on A+se side. Signed, , Title: Date:_,��—� i 7 FOR DEPARTMENT USE ONLY Application Accepted by. Date ` .r Arear x . 4 ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH a EH 1124 IREV.t/H 51 £H 14-26 6