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APPLICATION.FOR PERMIT SAN.JOAQUIN LOCAL HEALTH DISTRICT k 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone'(209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 3 1 1987 + , .. .. (Complete in,Tri.plicate) ENVIROMENTAL HEALTH Application is hepeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herei ton is l�nsv � made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and equations oft a San Joaquin Local Health District.' Job Address ` [ J . Cit Lot Size PM Owner`s Name Address Phone Contracto Address 0 6 License No. Phoneme' ;��t- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS x,11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ED Manteca Dia. of Well Excavation Dia. of Well Casing l XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' ❑ Public El Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation --Approx.'Depth ❑ Eastern f Surface Seal Installed by Repair Work Done L-1 . Type of PumpR c4—A-1- H.P. ��-- _ State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is t available within 200 feet:) f Installation will serve: Residence Commercial_ Other . Number of living units: Number of_bedrooms Character of soil to a depth of 3 feet:l Water table depth SEPTIC TANK ❑ Type/Mfg4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ [ i Method of Disposal ` Distance to nearest: Well Foundation Property Line . LEACHING LINE ❑ No. & Leng h of�l es `l� Total length/size ` + 14 i ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line :� ^ SEEPAGE PITS ❑ Depth `I Size Number tl fSUMPS ❑ Distance to nearest: Well Foundation Property Line k 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 regulations of the San Joaquin Local Health District. t_. ti • Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work-for-whichh this permit is issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 must �all�equired inspections. Complete drawing on reverse side. s Signed X Title: Date: l FOR DEPAR ENT USE ONLY '/ Application Accepted by Date �" �� Area �S Pit or Grbut Inspection by `, Date Final Inspection by _ Date . 11 .I. Additional Comments: I ElStk• 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Envirorimental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE K 4 INFO AMOUNT DUE ii AMOUNT REMITTED CASH RECEIVED BY. DATE PERMIT'NO. ! ,+ EH 13-241REV.1 /65] EH 1428