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j APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'f i'VV!'WiS A 1 15 1 J 1601 E. HAZE TON AVE., STOCKTON, CATelephone (209) 466-6781 PERMIT EXPIRES 'i YEAR FROM DATE ISSUED JUN 26 1989 (Complete in Triplicate) r '� j q,r 14his alion is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worktlter�I{t�2 I UG made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anrF1EfW0 srq P Joaquin Local Health District. !CV I Job Address a 5_ 6 'v City Lot Size PM CT Owner's Name Address Phone c { . _ . 1 Phone-' f Contractor Address icense N TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. POOP. LINE FOUNDATION sAGRICULTURE WELL w OTHER WELL--PITS/SUMPS — - l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i1 Public R Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Dept I i Eastern y Surface Seal Installed by - ' H. --. State Work Repair Work Done Type of Pump P. -[- Done �*�+ Well Destruction ❑ Well Diameter Sealing Material (top 50'I Depth Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION l I "DESTRUCTION l I (No septic system permitted if public sewer is t t Installation will serve: Residence— Commercial'— Other available within 200 feet.) '-'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 A"a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: f- Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑� Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line r......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 d rules and regulations of the San Joaquin Local Health Diltrict. , Q 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, l shall not (� 4 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature l� If 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 applic nt must call for all retidiins`� ctions. Com Iete dr ing on reverse side.Signed X �y'�/ ' Date: i Q F DEPARTM€NT USE,ONLY Application Accepted by. „ - yti .��- Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I I _ FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO GASH i y Q; Q� +.EH 13-24 4REV.F i n 51 ��1"�f a�” I y7,r EH 1426 "'LLL