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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT ' RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209} 466-6781 OCT 4 1988, PERMIT EXPIRES 1�YEAR FROM DATE ISSUEDk (Complete in Triplicate) : ENVIRONMENtgL HigL ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install �r� the wb5fiW0 STNS application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. yy,: Job Address City' Lot Size PM Owner's Name Address ��s / �7 - Phone Contractor 44 L Address 10°�iI/ icense No.4C4CZkb Phon I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTgON ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER at- DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION - - 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 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation Approx. Dell. th ❑ Eastern Surface Seal Installed by Repair Work Done L Type of Pump H.P. State Work Don Well Destruction ❑ Wel! Diameter Sealing Material {top 501 Oen:2 Depth I Filler Material ;Below 5011 Q 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_ "Commercial_ Other Number of living units: Number of bedrooms x Character of soil to a depth of 3 feet: Water table depth Leo SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ 4t Method of Disposal Distance to nearest: Well FouniMation Property Line LEACHING LINE ❑ No. & Length of lines 1- g Total length' FILTER BED ❑ Distance to nearest: Wellr Foundation Property Line SEEPAGE PITS ❑ Depth Size_ . -,A ?`' Number _SUMPS_ ❑ Distance to neareLl Well Foundation Property Line ' # DISPOSAL PONDS El �t hereby certify that I have prepared this ppMcation and thatthe work will be done in accordance with San Joaquin county ordinances, state laws, and Sin.Jq`ui rules and regulations of the SaoerS6cal Health District. Home owner or licensed agent's signature.certifies the following: "I certify that in the perfonflance of the work for whi_chAhis° ermit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California Contracil:6 s hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which_this:permit s issued•14'shall employ persons subject to workman's compensa- tion laws of California." The applicant ust all f I required inspections-CompI te_drawing on reverse side, Signed tTkle: ". /Y1QtJ Date: FOR DEPARTMENT USE ONLY Application Accepted by 'I Date y v 10,71 Area �_� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT 'tREMITTED CASH RECEIVED BY DATE" PERMIT/'NeO�. +EH 1426 3-26 EV.i/B 5) �[ '� _'-'r - t�S e'o -7033 m EH 1C� -