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APPLICATION-FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT / 1601 E. HAZELTON AVE., STOCK-TON, CA A t / Telephone (209) 466-6781 PERMIT EXPIRES 11,YEAR FROM DATE ISSUED pec {Complete in Triplicate) I _zs�3r �lViR 1988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work t� This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellJpump and the Rules �plpt 7A Ordinance Joaquin Local Health District.�Tts ��L'T'"/lm � t�(.A ��JJ J�V �•�''�GG�q�'rl t anaC1 Job Address t �" 1Gt+ City Lot Size PM Owner's-Name60 Address -7-1 l,L/• UA dJjl G J 11- LkP�,one Y .. � • 7Ti,Vl Contractor Address d cense No. �lr�ti Phone TYPE OF WELL/PUMP: U NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK + SEWER LINES DISPOSAL FLD. ♦PROP. LINE ,F FOUNDATION AGRICULTURE WELL OTHER WELL" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f +� )d Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r=�L?' Dia. of Well Casing 1 r ❑ Domestic/Private ISI Gravel Pack Oa Tracy Type of Casing 12 W-1 Specifications F1 Public C1 Other ❑ Delta Depth of Grout Seal Typp of Gr3rft LL - I Irrigation _._Approx, Depth I 1 Eastern Surface Seal Installed by' Repair Work pone ❑ Type of Pump H.P^ State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') ± �' Depth Filler Materia! (Below 50')" e O ` TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION l I DESTRUCTION I 1 lfVo septic system permitted if public sewer is (� 1 available within 200 feet.) Installation will serve: Residence_ Commerciale Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK .n Type/Mfg + Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Wel! Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED ❑. Distance to nearest: Well Foundation Property Line p Y SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation .Property Line DISPOSAL PONDS O 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 Diltrict. a 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 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 applic nt fnust call for all req 'ed inspecti ns- Comp to dr g on reverse side. hu Signed X U_ Date: FOR DEPARTMEN SE ONLY a� Application Accepted by - r Date Area m q C� Pit or Grout Inspection by ate Final Inspection by Date Additionaf Comments: ❑ SOr 456-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7164 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. •.EEH H14-29{REV.I/H51