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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 1111 Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED i U N 01 1990 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the . implication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the R es is bran Joaquin Local Health District. Job Address L + 1/v � S7 City Size PM Own 's Name s y r`t + Wt S Phone T 07 Contract tltlress I R Z License No.lua, 3 Phone TYPE OF WELL/PUMP: NE WELL ❑ 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout 1 I i Irrigation Approx. De th i I Eastern Su e Seal Installed by Repair Work Done (R/ Type of Pump MF% H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK; NEW INSTALLATION i I= REPAIR/ADDITION I I DESTRUCTION I I 1No septic system permitted if public sewer JS available within 200 feet.) installation will serve: Residence_ Commercial___- Other. Number of living units: Number of bedrooms it. Character of soil to a depth of 3 feet: Water table depth A 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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 rules and regulation e n Joaquin Local Health District. Home owner or ' ensed agent' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any p son in such man er as to become subject orkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the Ilowi g: "I certlf at in t pe ormanc f e work for which thi permit is issued, I shall employ persons subject to workman's compensa- tion laws Califo ia." The appl' a f all requ' d ' omelet drawing o Signed Titie: Date: ..2 APK DEPARTMENT USE ONLY - j Application Accepted by Date Area 1 ) Pit Or Grout Inspection by Date Final Inspection by – Date (J Additional Comments: [ t ❑ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH1 3-241REV.tiiN5l EH 14-28 5.v�