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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA FEB 02 1988 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV IRWENTAL HEALTH (Complete in Triplicate) A ( i{5EfWIrafi&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- IFJ SM ��y ( 0 0s 47.E 0—CJ Jots Address 2t` \ ` '`�'�_l. i ��Lia City C--1_,1 ` I- Lot Size PM i. Owner's Name 40� Address s T "d Phone q i � � '� { �- f Contract l[ a J S Addressli�� S��`„ ��icense No.f 2► Phone 214 l�; TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANKd�`Z,z_ SEWER LINESZ + DISPOSAL FLD. PROP. LINE �] - _ FOUNDATION AGRICULTURE WELL — OTHER'WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑'Industria! W"pen Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['1 Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout ��§Approx, Depth l 1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump � — H.P. State Work Done Well Destruction ❑ Well Diameter 14.1 Sealing Material (top 501 t I Depth ' Filler Material (Below 501 �o TYPE OF SEPTIC WORK: NEW INSTALLATION € I REPAIR/ADDITION I I DESTRUCTION I 1 (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 nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size F FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS: _ Ll 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 taws, 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed XiL] Title: Date: 'a-z-1 F5R DEPARTMENT USE ONLY A Application Accepted by Date ( .,, Area 041 Pit or Grout Inspection by Date Final Inspection by Date .a �.a" 0 Additional Comments: ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all pies to: Enviental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95,201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13-241REV. EH 14-28 I�