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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA --- Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVER (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heia��scribelil� 11Dpplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations o t e San Joaquin Local Health District. �Q W REAL' ONMENYAL H Job Address r;/ City Lot Size PERA T1Crpyr�� Owner's Name V n ress 4�`> ��11r�Ag% ) :t.� hone Contractor d4a d.-QfOtl-� Address"l�d-rsg:& License No.i4klm ��Phone TYPE OF WELL)PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR i OTHER QC 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 El Tracy Type of Casing Specifications (-I Public n Other C-1 Delta Depth of Grout Seal Type of Grout I I Irrigation — -Approx. Depth C I Eastern t Surface Seal installed by 4 Repair Work Done D1 Type of Pump.. 44t& H.P. T�& State AWork Done f Q\a Well Destruction D Well Diameter Sealing Material (top 501 Depth Filler Material 16elow 50') if TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION l I DESTRUCTION [ I (Nose t i i s er is avaiI b r 00 Installation will serve: Residence_ Commercial_ Other O Number of living units: Number of bedrooms AUG 1 D 1990 Character of soil to a depth of 3 feel: Water table d l SEPTIC TANK ❑ Type/Mfg Capacity FI NV� PKG. TREATMENT PLT. ❑ Met �E 't 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 l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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 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 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 applicant ust caU for all required inspections. Complete drawing on re iise si e-. Signed K '� =62�i� ir� -- f Title: -. Date: OR DEP RTMENT USE ONLY Application Accepted by Date O Area Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 0 Manteca .:623-7104 ❑ 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 C K R RECEIVED BY r DATE PERMIT'NO. + EH14-24 iREV.v H 5) D Q O EH 14-28 I •lt