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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ° I UN 1601 E. HAZEL T ON AVE., STOCKTON, CA J 3 1987 Telephone (209) 466-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED "ENVIROMENTAL HEALTH (Complete in Triplicate) .1:1 FERMIT/SERVICES. Application is hereby 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. 1$62 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. i� y Job Address --0-01 � '„r Clc3L city.. / ekfill Lot Size +3 PM r y ' e A :u Owner's Name �, t/ ddress _ �y Phone - Contractor / Address f } ?'� - � License No, Phone TYPE OF WELL/PUMP: `� NEW WELL ❑ WELL REPLACEMENT--ED DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 3 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESt.DISPOSAL_FLD, Y PROP,`-LINE - FOUNDATION AGRICULTURE WELL + OTHER WELL PETS/SUMPS INTENDED USE ;TYPE OF W C1 InELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS dustrial ❑ Open Bottom E Manteca Dia. of Well Excavation Ike Domestic/Private ❑,Gravel Pack Dia. of Well Casing ❑ Trac ❑ Public ; � y Type of Casing Specifications { Q•Other ❑ Delta Depth of Grout Seal ❑ Irrigation i Type of Grout g �pprox. Depth ❑ Eastern i rface Seal Installed by Repair Work Done W Type of Pump ,'_ __ H p f State Work Done 1IV �• � � �r h, Well destruction El Wel! Diameter - Sealing Material (top 50') j I+r��°% 7/ - Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_ Other r available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet ;, : ' In, s ,l., f - ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity P y No. Compartments PKG. TREATMENT PLT. ❑ t �« s 11 p Method of Disposal Distance,to nearest: Well Foundation r` Property Line " aiy-4 4 - LEACHING LINE ❑ No. & Length o6iries, _ Total length/size ElW FILTER BED Distance,to nearest: ell �lFoundation F Property Line SEEPAGE-PITS--- —, -❑_-,Depth-====4.7 — _Size:.,.._._..,- �,� _tel . SUMPS ❑ Distance to nearest: Well f=oundation PONDS ❑ i Property Line -r- DISPOSAL l - 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-contacting signature certifies the following: '9 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." ,��.` is The applicant t call for all requi ed inspec, ns. Complete drawing on reverse side. Signed Title, e�yL Date: 0 �yy} F011 DEPARTMENT USE ONLY g/� Application Accepted by / ' r �C� Date Area �.zon by "i.1 O Pit or Grout Inspecti Date Final Inspection by / s F = -fAdtlitional Comments. � � �.. ; Date �p _ ❑ 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 J FEE AMOUNT DUE AMOUNT REMITTED CK# INFO E RECEIVED.BY DATE PERMIT•'NO. + EH 13-24(REV.1/e 5) / � EH 14-26