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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 UU 2 PERMIT EXPIRES 1 YEAR_ FROM DATE ISSU ' , ) (Complete in Triplicate) AUG 91988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desr' , application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump ar1r1NV"MEb1 _llSan Joaquin Local Health District. ( _ FERMIT/SERVICES" Job AddressR/C7 ,J _QIi" CkA. _ _ City DA4G _� Lot Size PM 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 Di?;trict. 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, 1 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." mu The appli I for all required inspections. Complete drawing on verse side. Signe Title: ► f�j�� —�- Date: _ -"� � MODEPARTIVIENT USE ONLY - Application Accepted by P� %f Date CPe CJ Pit or Grout Inspection by ✓ Date Final Inspection Date Additional Comments: ❑ Stk E 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 •, EH 13-24 MEY: r / K 51 EH 14-28 FEEINFO v p 7 Owner's Name Address C7.� L��Phone _ Contractor`Jc%e{�+, l� e c Address Y fl�o License No. g46� r �G�tr Phone:% TYPE OF WELL/PUMP: NEW WELL LJ 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ppomestic/Private ❑ Gravel Pack ❑ Tracy Type .of Casing Specifications ❑ Public ❑ Other T1 Delta Depth of Grout Seat Type of Grout . I I Irrigation f _____Approx.:Depth I I Eastern r Surface Seal Installed by Repair Work Done ❑ / Type of Pump( H.P.:��y— State Work Done Well Destruction E) Well Diameter } Sealing Material (top 50') Depth I JFiller Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l:) REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) c Installation will serve: Residence Commercial _ Other Number of living units: Number of bedrooms a Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg p'' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line .I SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ j 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 Di?;trict. 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, 1 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." mu The appli I for all required inspections. Complete drawing on verse side. Signe Title: ► f�j�� —�- Date: _ -"� � MODEPARTIVIENT USE ONLY - Application Accepted by P� %f Date CPe CJ Pit or Grout Inspection by ✓ Date Final Inspection Date Additional Comments: ❑ Stk E 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 •, EH 13-24 MEY: r / K 51 EH 14-28 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT -NO. I.,