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II APPLICATION FOR PERMIT PAYMENT SAN JOAQU IN LOCAL HEALTH DISTRICT RECEIVED li 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 AUG 17 1987 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i! (Complete in Triplicate) ENVIRONMENTAL HEALTH 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.CountYOrdinance_No:.549_for.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.' C Job Address n?71 LSA : Q m-fes" 1 city Lot s;ze �CYe, Pnn �flr Owner's Name 1 /V` ( � Address 8� I Phone77Q-2-794 Contractor Address a - 1 .License No. OZI Phone TYPE OF WELL/PUMP:. NEW WELL.X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK none SEWER LINES ,DISPOSAL FLD. PROP. LINE +� FOUNDATION AGRICULTURE WELL OTHER WELL_ Me. PITS/SUMPS =' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. z/ Dia. of Well Casing 1 { Domestic/Private V Gravel Pack Tracy Type of Casing ' ' ' Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �Rbr tJCJ Type of Gr t ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') a Depth- Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 0 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other -. Number of living units: -Number of bedrooms i Character of soil to a depth of.3 feet: Water table depth SEPTIC TANK ElType/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance.to nearest: Well Foundation Property Line q LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest:-1 Well'1-- `-- Foundation " ' '--Property-Line =—• DISPOSAL PONDS ❑ �I Y 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 o California." i - The applic t st call for all reqire ' spections. mplete drawing on erse sid . Signed Title:A 7 Date: iU FOR DEPAR7UENT USE ONLY Application Accepted by M, 4 21 Date –77 _ Area Pit or Grout Inspection by ata Q '`f Final Inspection by Date Additional Comments: `06 r se "i oo — ❑ Stk 466-6781 ❑ Lodi i 369-3621 ❑ Manteca 823-7104 ❑ Trofty 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952FEE (C ` INFO ^AMOUNT DUE AM9UyNT REMITTED K RECEIVED BY DATE�y� PERMIT'NO. + EH13-24(FIE V.1/a51 [ EH 14-28