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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 2 8 1987 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 EHVIROMENTAL HEALTH PERMIT EXPIRES TYEAR FROM DATE ISSUED FERMITAERVICES a I (Complete in Triplicate) ,Application is hereby made 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 Disstrict. '. ` may,, � Job Address IS--IS— l/tJ �f�i✓�cI� City F� /Lot Size PM Owner's Name 041600' Address" 7 4"`a — +/b Phone i'—P2 71 000 Int �S v, fd c�P�� 3G � Contractor Address r ; ie ar�cr�.�- License N��.� 74 / PhoneI74K—f 33 ? TYPE OF WELL/PUMP: . �NE-W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS INTENDED USE TYPE OF!'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca pia- of Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications (� 1'1 Public F1 Other F1 Delta Depth of Grout Seal Type of Grout V 41 I Irrigation Approx. Depth I I Eastern Surface Seal Installed'by Repair Work Done Type of Pump Ute. H.P. _ I State Work Done r2e ,-4,4C6- Gpl-4 fiy07� ` Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material 03,1,w 501 TYPE OF SEPTIC WORK: ..NEW INSTALLATION (I REPAIR/ADDITION I.I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ 4tKei 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 p PKG. TREATMENT PLT. ❑ Method of Disposal 4 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _ i FILTER BED ❑ Distance to nearest: Well 'Foundation Property kine } SEEPAGE PITS I I Depth Size s. Number x SUMPS ❑ Distance to nearest: Well s 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 4 Home owner or licensed a nt'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 suc! anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I c ify that i the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California.' The applicant must re ui d in ctions. Complete drawing on reverse side. ,. µ Signed.X h Title: A' L - Date: ' t - - FOR EPARTfN T USE ONLY , Application Accepted by � date � Area Pit or Grout Inspection by Date Final Inspection.by Date 1 M Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all Fcopies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMWNO. + EH 13-241REV.i)115) EH 14-26