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,..i~ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone 52091 466-6781 REICOVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APR — 9 1989 {Complete in Triplicate) SAN JOAQUIN COUNTY lftlr,HEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins �q(�� rf��rpq�b .r�l�i� ication is made in compliance with San J quip Co ty Ordinance No.549 or sewage or 1862 for well/pump aAt PuiA0'rfd'f!- atL of the San Joaquin Local Health District. Job Address Cit Lot Size PM Owner's Name nnAddressr Phone _ Contractor Address �C !Sr n�se�No. S�o� Phone�L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ IC PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ;PROBLEM AREA. CONSTRUCTION SPECIFICATIONS .- ❑ Ind I ❑ Open Bottom anQ'M teca Dia. of Well Excavation Dia. of Well Casing Il stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f=ubt,c 9 ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I 1 IrrigationApprox. Dept ( Eastern Surface Seal Installed by Repair Work Done CS Type of Pump H.P, _3 State Work Done Well Destruction ❑" Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 0 available within 200 feet.i r Installation will serve:;. Residence____ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ii Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines .Total length/size (� FILTER BED 'I ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS a l I Depth Size Number — � SUMPS :: Ll Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ I.hereby-certify-that-1-heve-prepared this application-and-that-the-work-will s:be-done°in-accordance-with'Sari Joaquin-cburity'brdinantes;st'atelaws,and 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 t 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,l shall employ persons subject to workman's compensa- tion laws of California.". The applicant must call for all required inspections. Complete drawing on reverse side. ® �} Signed Title: � �� _.... Date: �l� FOR DEPARTMENT USE ONLY pP P y Date Area Application Accepted b y a / / " ,l Pit or Grout Inspection by Date Final Inspection b Date ; Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH113-24(REV.r/n 5) EH 10-28 � �0 O �f