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3`-9 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA �cti ) Telephone (209) 466-6781r�8 d PERMIT EXPIRES TYEAR FROM DATE ISSU j;. 1988 (Complete in Triplicate) p ON41" /QlesSn Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo�llThis application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules �e San Joaquin Local Health District. Q , "� ! l /tel •E�' `h cit .C.J/)�. (�at size �v+ 7YF-1- 365. Job Address Y Owner's Name 70 A/ Address ` Phone Contractor Address �� license No. / Phone r TYPE OF WELL/PUMP: _ NEW-AVELL--Q WELL REFxLACEMENT i❑ 'DESTRUCTION ❑ TAL�t DISTANCE TO NEAREST:.SEPTIC TANK I� µSE 1ER� IL N�SYSTEM REPAIR DISPOSALFLFLP.'HER ❑OP. LINE FOUNDATION AGkooUL--TUBE WELL —/OTHER WELL ..PITS/SUMPS d — ----INTENDED-USE _TYRE=O.F_WEL-L..y__ PROBLEMAREA._-_CO1V_S_TRUCTION.SrPECfFICATIONS_ i _ t "0 ❑ Industrial ❑ Open Bottom LJ Manteca `� Dia. of Well Excavation`I I Dia. o� ff Well Casing I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I II s Irrigation --Approx. Depth l ] Eastern Surface Seal Installed byc Repair Work Done ❑ Type of Pump2� � H.P. 7�CJ i # ' tate Work Done Well Destruction ❑ Well Didmeter Sealing Material Itop 50') -�` � � T, Depth Filler Material tBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIWADDITION I I DESTRUCTION l I (No-septicF��ystem permitted if public sewer is ava lablei thin 200 feet.) Installation will serve: Residence_ Commercial Other '� II 4` `fes x Number of living units: Number of bedrooms -- if r' r Character of soil to a depth of 3 feet: I _ _Water table depth; SEPTIC TANK ❑ Type/Mfg ICapacity� No. Compartments PKG. TREATMENT PLT. ❑ i Method o�6i'posal Distance to nearest: Well Foundation ` P operty Line LEACHING LINE ❑ No. & Length of linesg T Total length/ --.-. FILTER BED ❑ Distance to nearest: Well Foundation Property Line I s r SEEPAGE PITS I I Depth Size ! Number y.. SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ # I hereby certify that I have prepared this application and that the work will be dor1din accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , t 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, I shall not employ any person in such manner as to become subject to workman`s compensat aril laofof California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which I'Ss Permit iA issued, l shall employ persons subject to workman's compensa- tion laws of California." j The applicant�requr r ns. Complete drawing on raver a side. Signed X Title: Date: Id,13 FOR DEPARTMENT USE OLY t' i � p Application Accepted by Date la&SX/ Area � 2- Pit or Grout Inspection by Data 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 lFEEO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT•NO. a.EH 13-24 IREV.r i H 51 d EH 14-26