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` T APPLICATION FOR PERMIT V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.- STOCKTON, CA Telephone (209) 466=6781 ori;Q 19 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �� (Complete in Triplicate) h/ Q 40 �I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describeddtion 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 �QL� CityfaY_ K/ Lot Size PM r� f r Owner's Name �J 1- ddress Phone Contractor's Name r�eJ Oma/ r License No. Phone —Z2-d 7 TYPE OF'WELL/PUMP:. ` ► .-NEW WELL ❑ \ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP`INSTALLAT16N ❑ SYSTEM REPAIR A OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE TFOUNDATION•"a AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing 0(Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other O'Delta Depth of Grout Seal Type of Grout �y ❑ Irrigation ---Approx. Depth Eastern Sur#ace.•Seal, Installed by I �` Repair Work Done 19 Type of Pump H.P- l� . � State Work Done ¢ J Well Destruction ❑ Well Diameter Sealing Material {top 5_01 " Depth Filler Material IBalow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION-❑ (No septic system permitted if public sewer is available within 200 feet.) 1 Installation will serve: Residence_ Commercial_ Other Number of•living-units:--L----.—Number-of-bedrooms- Character of soil to a dept h.of 3 feet: Water table depth .r' SEPTIC TANK- O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal V, Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size o a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number i SUMPS ❑ 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 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 of California." The applicant t call for all r U. d ' ctions. Complete drawing on Fa%si j J q �f i Signed Title: l .t �� Date: I/ _ oC� '97 FOR DEPARTMENT USE ONLYof Application Accepted by Date ( Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy Applicant- Return all copies to: Environmental Heath 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. + EH 13-24(REV.10183) EH 14-26 S. A s