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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL. HEALTH DISTRICT Kt(;EIVFMLJ 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 10 19$9 IPERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRQNM NT�i. HEALTH 4 (Complete in Triplicate) t A,�I T / p,�d kation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work WdNt , isEf1 io 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 an Jbaquin Local Health District. ` �+� � City Lot Size PM Job Address / 7 /�-2�C/C�+ � — &_1C _ Phone37 —/2 Owner's Name Address/�� ! Address6 �` License NoJ h i-3 711 -Phone / '7 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ iw"r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WEL J PROBLEM AREA CONSTRUCTION SPECIFICATIONS rre► ❑ Industrial ❑ Open Bottom E3 Manteca Dia. of Well Excavation Dia. of Well Casing { Specifications [4. -Domestic/Private ❑ Gravel Pack / ❑ Tracy Type of Casing I Type of Grout ["1 Public ��D Other " ❑ Delta Depth of Grout Seal I I Irrigation Approx Dept l i Eastern Surface Seal Installed by Repair Work Done T pe of Pump H.P. State Work Done Well Destruction ❑ Well Diameter #V Sealing Material (top 50'1 Depth �' { � Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septiclable system hin m permitted if public sewer is r Installation will serve: Residence=�- Comrriercial e 1'`'other ___ Number of living units: Number of,bedrooms ' j ,* Jl A \% ;s Water table depth ' Character of soil to a depth of 3 feet: '� Capacity. ' No. Compartments SEPTIC TANK ❑ Type/Mfg i Method of Disposal PKG. TREATMENT PLT- ❑ I \�"' 2 �. Distance to nearest: Well F611h'dati6n Property Line LEACHING LINE ❑ No. & Length of lines ,�; Total lengthlsize FILTER BED ElDistance to nearest: Well \k' Foundation Property Line 1ir l SEEPAGE PITS { 1 Depth Size f` Numbe r ' Property Line SUMPS L1 Distance to nearest: Well Foundation DISPOSAL PONDS ❑ } �` l hereby certify that I have prepared this application and that the work wil! be done in accordance witfl-5an Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin Local Health Di1trict. ` Y Home owner or licensed agent's signature certifies the following: "I certify that iri•the performance o1 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 int he performance of the work for which this permit is issued, I s fall employ persons subject to workman's compensa tion laws of California." The applicant mu t cat for all requ'ed inspections. Complete drawing on reverse side. �', j ., r ,,lTitle: Date: Signed X - j LL- i EPARTMENT USE ONLY Data_ — Area Application Accepted by ,�''�'``��,� � Date-! Pit or Grout Inspection by Date Final Inspection �- rt Additional Comments: ❑ Sik 466-6781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Perm tlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT•NO. INFO �`AMOUNT DUE AMOUNT REMITTED CASH I 7 3! t 89 a 7 r EH 13-24(REV.1/H 51 S EH 14-26 I