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�. _ _______.ter_•�� - ; APPLICATION FOR PERMIT Igi%R ; SAN JOAQUIN LOCAL HEALTH DISTRICT ��. k 1601 E. HAZE I ON AVE., STOCKTON, CA tt Telephone {209) 466-6781 a!l� `� 1987 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tl N. (Complete in Triplicate) ENVIRONEAL HEALTH }T/SERVICES Application is hereby made to the San Jo quin Local Health District for a permit to construct and/or install the work herein d . . This application is made in compliance with San Joaquin Co'u ty Ordinance No.549 for sewage or No. 18622 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. t I; e Job Address //U� �,/� — City e2, � o Size PM Owner's Namery+5 Address Phone Contractor � wA�d.dere ss6�� f '05' License No.-'&9gJX Phone / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIOND CeAA1VK+-/WX-A19YSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seat Installed by Repair Work Done ❑ Type of PumpS/l�R/& H,P. Z- State Work Done_8999 Well Destruction ❑ Well Diameter Sealing Material (top 501 S/,f3 ! e"2t -- Depth ( Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will se le 1Res d... �—�A£Commercial_ Other Number-of-living-units:- ---Numbs o4lldr�ums Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK Q Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ }} Method of Oilposal Distance to nearest: Well t Foundation Property Line LEACHING LINE ❑ No. & Length of line sj < Total length/size FILTER BED ❑ Distance to nearest:/`j1;. Well Foundation Property Line SEEPAGE PITS ❑ Depth Size i Number S j. SUMPS LJDistance to nearest. '� Weft f'l Foundation ` •Property Line DISPOSAL PONDS ❑ ' I hereby certify that I have prepared this application and that the work will be done in accordance with Sanr.loaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1__ 1 Home owner or licensed agent's signature certifies the following: "I certify_that in the pe ormance of the work for which this permit is issued, f shall not employ any person in such manner as to become subject to workman's cdmpensation la ws'of\California."Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of the work fpr which`this permit is issued,I shall employ persons subject to workman's campensa tion laws of California." 1 The applicant mu c II r I requi pections. Complete drawing on re rs ids. Signed Title: Data: g 7 ' FOR DEPARTMENT USE ONLY Q j Application Accepted by Date '�"- 4� l Area i Pit or Grout inspection b Date Final Inspection by / Dat Additional Comments: S7% ❑ Stk. 466-6781 ❑ Lodi 369-36211 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. + EH1 -24(RM t/85) EH 144-26 t I