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V, " APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT D CIO O 1601 E. HAZE I— •N AVE., STOCKTON, CA Telephone (209) 466-6781I . ItSES 3 1987 PERMIT EXPIRES'1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH A lication is hereb made to the San Joaquin Local Health District for permit to construct and/or install the w R 1T' SlRVECE$. . „ Pp Y q p a TT�f�tl�scnbed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and-Regulations of the San Joaquin Local Health District-" Job Address b �Q• G%�f' a City Lot Size'r ; y PM ' €, 14 ' Owner's NamAddress 7a� �o� �� `` Phone$�� Contractor •Address ra License No. �-�,3� 7�(��— Phone� 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 t AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIONS- I, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout l ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done E3 Type of Pump;Ike r-Q— H.P. State Work Done Well Destruction ❑ Well Diameter) Sealing Material (top 50') 1 Depth Filler Material !Below 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_lCommercial_ 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. ❑ .Y.-Method-of.Disposal ; t Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ ' No. & Length of lines ( Total length/size `r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 1 Size Number. SUMPS ❑ Distance to nearest: Well Foundation Property Line F]DISPOSAL PONDS r v` 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 i rules and regulations of the San Joaquin Local Health District. Home ownerOT 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 tail for all re u inspections. Complete drawing on reverse side. Signed)L r .4 i Title: - Ger Date: _ s FOR DEPARTMENT USE ONLY Application Accepted by v 1 V I rn inDateTr) Area // Pit or Grout Inspection by Date Final Inspection byWIVI Date s jb Additional Comments: 1 Stk 466-6781 ,❑ Lodi 369-3621 _, ❑ Manteca 823-7104 - LlTracy 835-6385 plicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - r i FEE INFO =`AMOUNT DUE, +1 AMOUNT REMITTED GASH RECEIVED BY (�7 DAT///E�� PERMIT'NO. Y '+ EH 13.24 1REV.I H 5] �_ EH 14-28 `' l" T' F