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APPLICATION FOR PERMIT ., SAN JOAQUIN LOCAL HEALTH DISTRICT 1i j 16301 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 SEP 2 71988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVPERUMIj SEi2ViCI SLI; Application is hereby made to: he San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with SantJoaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address Q /C City Lot Size PM Owner's Name /C�gGII L! 7 .��_ Address yC�"/�/�'l� Phone Cohtractor' �S Addres _ License fro. '�Phone i TYPE OF WELL/PUMP: �! NEW WELL ❑ WELL REPLACEMENT 1=7 DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER uNtsl 11_��`A.p p A)_ FLO. PROP. LINE # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREACONSTRUCTION SPE IF9A ❑ Indusirial ❑'Open Bottom LI Manteca Dia. of Well Excavation- ` Dia. of Well Casing Domestic/Private O'Gravel Pack -_ElAI y N` Type of Casing— ) ��;7,� YpSpecifications M Public Lf`Oxhet "^ '{ -Delta— .t-- Depth o1 Grout Seal Type of Grout I I Irrigation j��-A�- "� rg I 1 _ pprox. Depth i I E sterri . Surface Seal Installed by Repair Work Dane ❑ Ty'pe of Pump H.Pi.T}l _ State]Work Done_ Well Destruction ❑ V.61 Diameter 01Sealing }Material Itop 50') pth Filler Ma#eriaH9etaw-501 TYPE OF SEPTIC WORK: NVEW INSTALLATION [1 REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is p } � available within 200 feet.) l?� Installation will serve: Re it`ence_ Commercial_ Other W r Number of living units: -��I Number of bedrooms Chara&r of soil to a depth4 of 3 feet: Water table depth } SEPTIC TANK ❑ 'T /Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .1 �. Method of Dispos , Distance to nearest: Well Foundation Property,Line ter✓ �� LEACHING LINE ❑ I'No. & Len Length of lines O ;i g Total length/size 6 FILTER BED ❑ "Distance to nearest: Well Foundation Property Line SEEPAGE PITS' I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t ` DISPOSAL PONDS ❑ I hereby,certify th�I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulAons of the San Joaquin Local Health District. Home owner or licensed ageM'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 rnariner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifiesfthe 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 applican u o all re tions. Complete drawing on reve side. l Signed' I I� itle: Date: FOR DEPARTMENT USE ONLY lk Z Application Accepted by Date '� 7L37 Area Pit or Grout Inspection by iI- Data Final Inspection by Date Additional Comments: -- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applica. t- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM UNT DUE AMOUNT REMITTED CK 4T CASH RECEIVED BY DATE PERMI-r NO. " m Q +.EH 13-24 IRM 1/05) EH 14-211 {