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ftAl� cr APPLICATION FOR PERMIT } r f SAN JOAQUIN LOCAL WEALTH DISTRICT I 1601 E. HAZEL T ON AVE., STOCKTON, CA OCT E 1987 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMLNTAL HEALTH (Complete in Triplicate) PERMIT/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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. -,, r Job Address i J�� f_ /�Y + l�c�I1 404,e . City I!yd Lot Size PM a Owner's Name — alb ; NYU i�1 Address 12 ct 3 S Phone 3 /" Contractor Address + -Q " iiccense No.3q/6 6 Z— Phone " �3�ot'elf TYPE OF WELL/PUMP: NEW WELL-N WELL REPLACEMENT Q . DESTRUCTION ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �.— DISPOSAL FLD.� PROP. LINED FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS-' +r ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation 43 pia. of Well Casing s Domestic/Privates ��.v❑�`gG�ravel Pack ❑ Tracy Type of Casing 7 Specifications j r Public }�(alf ther Q Delta Depth of Grout Seal Z_2_a-0 r T pe of Grout.-._.._ I I Irrigation 1 a _.Approx, Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ Well Destruction Q Well Diame Sealing�terial top 50') Depth Filler low 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION i I DESTRUCTION I I (No 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. ❑ Method of Disposal Distance to nee Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Fo ion Property Line SEEPAGE PITS I 1 Depth a Number SUMPS ❑ Distance to�ll 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 Californi ." The applicant must a or,all.required in: ctio omplete drawing on reverse side. —7 Signed X _ � � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 01 Area Pit or Grout Inspection b • (5 Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 CASH RECUVED BY DATE PERMIT'NO. y EH 1 -24(REV.,i N 51 EH 4 O 0/ r/-/ 1 .j•