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ri Fk Q1 APPLICATION FOR PERMIT _ UANAN -� n - sr, JOAO,UIN LOCAL HEALTH DISTRICT �f BEC 2 9 1983 1601 E. HAZELTON AVE., STOCKTON, CA r= Telephone (209) 466-6781 �r'fO'', 4; ani LCu � SAN .�i, AQUIN LOCAILERMIT EXPIRES 1 YEAR FROM DATE ISSUED f JE,"t TM, DISTMil H LTH D)STRjC l (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin LocalHeattQfte o Job AddressSai !fit 1, t }^ •, 'i�O �o vT„&erot t* G, City w Lot Size ”' PM } Owner's Name ► C S Address Phone Contractor's Name 101 k GAJ License No. Phorc Y,7LOZO TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � Y Ce Q S �iCrrv<� ap+ .:DISTANCE TO NEAREST: SEPTIC:TANK< - SEWER.LINES" -=� - =,�_�DISP-QSAL-FLQ.--- .PROP: INE_ -- - 1 y _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Z i`� _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIQNS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal a Ty a of Grout ❑ Irrigation --Approx. Depth El Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number -- SUMPS +(fl—Distance to nearest: Well -FMihdation Property Line DISPOSAL PONDS ❑ 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 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 f wing:"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 la of a'fornia." The ap "ca m st call for I re qui a spections. Complete drawin on reverse side. Signed a Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byV `Date 1'— Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ ❑ 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 yA�MOUNT REMITTED GA�.SH�7 �RECEIVED BY DATE PERMIT NO. +EH 13-24(REV.10/83) �! 0- i o EH 1428