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+ APPLICATION FOR PERMIT ' ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT k Telephone (209) 466-6781 RECEIVEL) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) AUG 3 7988 T - Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workap lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No..1862 for well/pump and the Ryles an �� T IT Local Health District. �4 r+ /SERVICES k Job Address _ �y d.LG 3` r ty t Size' Y Y C� PM r 1t? & • f r� ,.. Owner's Name Address +) Phone Contractor 1 Address,//_ fI4-,"g ii-e; icense No. -.-d—Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 51�. J. 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 SPECIFICATIONS ❑ industrial E3Open Bottom F-1MantecaDia. of Well Excavation Dia. of Well Casing IX Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications x ' ❑ Public ❑ Other ❑ Delta . Depth of Grout Seal Type of Grout' ❑ Irrigation --Approx. Depth ❑ Eastern I. 'i; Surface^Seal lnstalled !y Repair Work Done . Type of P.ump" -=,. � _' H:P:3 � �- _ State'Work Done'" Well Destruction ❑ Well Diameter; �SeAing Material (tow50') Depth Filler'Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ *REPAIR/ADDITION LJ DESTRUCTION ❑ (No septic system permitted if public sewer is I ' ' available within 200 feet.) _ Installation will serve: Residence_ Commercial"?y Other Number of living units: Number of bedroom's. I Character of soil to a depth of 3 feet: 'r+) i_. _.: ' _ Water table depth i SEPTIC TANK CJType/Mfg Capacity _- N o..Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance tolnearest: Well o A Foundation Property Line SEEPAGE PITS ❑ Depth r _ 4 Size ` t Number I SUMPS ❑ Distance to nearest: Well. V Foundation Property Line I .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, and ✓ j 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, i shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractors 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 applicant must II all required in pections. Complete drawing on reverse side. {.. Signed Title: Date: f FOR DEPARTMENT USE ONLY M Application Accepted by 4D Date U4 Area Pit or Grout Inspection by i Date Final Inspection by Date ,lv '!�- j Additional Comments; ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE �, AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. fes, r + EH13-24iREv.t/as) [ 35• �v 36' - w{�� ✓Yl B' �p-��C} EH 14-26