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APPLICATION FOR PERMIT IgoA w SAN JOAQUIN LOCAL HEALTH DISTRICT ]� 1601 E. HAZEL T ON AVE., STOCKTON, CA ?; Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIROMENAIAL HEALTH {Complete in Triplicate} EE.RMITAERVICES Application is he+eby 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 San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. n Job Address •7mi N of Wile Rd 1mi E of J K TCM*e_ Lot Size PM Owner's Name John DeM rtin1 p J Address 92 9 k Phone Contractor Purviance D 111 Address License No. 37792.3—Phone 887-3554_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Er, pip repair DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WI=LL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J) 171Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing [I Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout r I I Irrigation Approx. Depth l,1 Eastern Surface Seal Installed by Repair Work Done )' Type of Pump t4Y I e- H.P. � State Work Done pill! Llm replac- Well Destruction ❑ Well Diameter Sealing Material (top 501 bowl _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED E7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number _ SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "t 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 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 applyust call r al quired inspections. Complete drawing on reverse side. Signed X c Title: President Date: 1/31/88 ll DEPARTMENT USE ONLY Application Accepted by �� Date Area (, Pit or Grout Inspection by Date_ Final Inspection by nDate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 111 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV,I/a 51 _ - EH 14-26