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APPLICATION FOR PERMIT AN QUI 516001 E. HAZENi ONLOCAL AVE STOCKTON, CAT R E C E I ays E I Telephone (209) 466-6781 AUG 14 1930 PERMIT EXPIRES ILYEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH FARM ICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor scr his application is i 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. Job Address f L I 46 J� 'moi" City Lot Size PM Owner's Name Address Phone f OF Contract — cw-- _ Address d �� Gr -94License No, ^��_� _Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )}omestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing Specifications M Public f I Other l l Delta Depth of Grout-Seal— Type of Grout _ I I Irrigation �..Approx. Depth l I Eastern Surface Seal Installed by _ '1 _ Repair Work Done Type of Pump q � H.P. �� R' State Work Done�� l W� Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I i DESTRUCTION € I (No septic system permitted if public sewer is r 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 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 I 1 Depth Size Number SUMPS 0 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 Di1trict. 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call t r a I required inspections. Complete drawing on r erre side. Signed X Title:°� Date — � J;c DEPARTMENT USE ONLY 0,0 Application Accepted by date Area Pit or Grout Inspection by Date Final Inspection by Date .2 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 tMOUNT DUE AMOUNT REMITTED GASH RECEIVED By DATE PERMIT NO. a.EH 13-24 IREV.I/1151 r Ilia ��_ EH 14-26 ` (�