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APPLICATION FOR PERMIT 7 � - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE' TON AVE., STOCKTON, CA o Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 5 1987 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workM � LbW- A1�s *14 is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and l4 1Tr%1,ft�loaquin Local Health District. tttfKC�9Vy�l ll .��r-- Job Address City 4' __ '�' of Size PM Owner's Name ' Address t fo Phone Contractor_ Address 74. A � � License No.IL L7 Phone -q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER F-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE bF'WECL PROBLEM AREA CONSTRUCTION SPECIFICATIONS --t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I Irrigation —.-Approx. De th l I Eastern Surface Seal Installed by � ��Aq - Repair Work Done ❑ Type of Pump �.-._ H.P. State Work Done :�+�'� Well Destruction ❑. Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 3 REPAIR/ADDITION l 3 DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) fi Installation will serve: Residence— Commercial_ Other 3 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll 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 accord3rice 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 shall employ persons subject to workman's compensa- tion laws of California." Theapplicantfscall�frall requir inspections. Complete drawing o reverse side. n Signed X itle: ?-- Date: FOR DEPARTMENT USE ONLY yy�� Application Accepted by Date to' IRkr) Area Pit or Grout Inspection by Date Final Inspection by OL. Date Additional Comments: Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH //4� r + EH 13-241REV.1/45) _ tV C%2 EH 14-26