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APPLICATION FOR PERMIT ,. SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED # (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 an Joaquin County Ordin nce No. 549 for sewa r No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Lot Size PM Owner's Name Address hone)4/f " Contract P idress , 1 License No, TYPE — TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI 5 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excava ion Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \ ^Z Fl Public CI Other Fl Delta Depth of Grout Seal Per TYPa of Grout 3 I ric anon � Approx. Depth I I Eastern Surface Sea! Installed by f o�J Type of Pump H.P. State Wor Done- Well , Destruction ❑ Well Diameter Sealing Material Itop 50'I 1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION IJ DESTRUCTION I 1 Moseptic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence= Commercial— OtherI Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. C7 Capacity No. Compartments " Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ` Well Foundation Property Line SEEPAGE PITS I I Depth Size Number :t SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q 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, f 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 app"c t ust call or all r q ed ins ct mplate drawing on reverse side. Signed X Title._�j FA: c B r `— - l it Date: TEC] 6 1988 � FOR DEPARTMENT USE ONLY / Application Accepted by Date_ ��/ i Are k Pito Grou spection by Date �J7— Final Inspection by Date Additional Comments: tGGJOf ❑ 5tk 466-6781 El Lodi 359-3621 ❑ Mante 823 7104 F] Tracy 835 6386 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO '7 K H RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREY.r/n 51 /� �ice] _�j EH 14.29 (�