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I` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 mr" PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) FEB 2 6 1991 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the iwarkjhereirn.described.+This application is made in compliance with San Joaquin County Ordinance No. G^. or sewage or No. 1862 for well/pump and the Rubs anY!Aegt�fation iif°thg'S- n�11c Win Local Health District. sem'`�:_ :,�. �-»�w P'EM-)10 i�:E�'D"40ES Job Address a . _ City Lot Size PM Owner's Name Address Po 6 J� Phone Contractor Address �J License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION _ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK T SEWER LINES DISPOSAL FLD.' —PR6P7CNE-"" - �* FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Ind trial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack R<11-cy Type of Casing Specifications s ©Q M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —..Approx. Dept JI Eastern Surf Seal Installed by 11 Repair Work Done ❑ Type of Pump H.P. State Work Don Well Destruction ❑ Well Diamete Sealing Material {top 501 Depth Filler Material !Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) 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 TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ f r A Method of Disposal Distance to nearest: Well Foundation Property.Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ' Distance to nearest: Well '' Foundation+ Property Line SEEPAGE PITS i 1 ' 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 shall employ persons subject to workman's compensa- tion laws of California." y The applicant must cal for all qu- d inspection Complete drawing on reverse side. jJ Signed Title: Date: r r , Y FPA DEPARTMENT USE ONLY Application Accepted by _ bate Araa /� .+" Pit or Grout Inspectionby " Data Final Inspection by Date 19 qf' 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 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT"NO. +.EH13-2A{REV.i,HSr U ! �.. rJV ./YA/t1 �_�"7_Q[ EH 14-2a C"J P / I 1 .Oa