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APPLICATION FOR PERMIT D � SAN JOAQUIN LOCAL HEALTH DISTRICT 111601 E. HAZETON AVE., STOCKTON, CA I AUG 21987 Telephone (209) 466-6781 I 1 ENVIROMENTAL HEALTH PERMIT EXPIRES 1-YEAR FROM DATE ISSUED FERMIT/SERVICES (Complete in Triplicate) rApplication 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 ii Local Health District. Job Address City Q - Lot Size PM r^ aJ f6� �g Ia 5 r'�t t" Phone "l �, — 36 Owner's Name &k)1)_4 T�� ° ��Address s _ Contractor ddress f � License lVo. Phone TYPE OF WELL/PUMP: NDAWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR., OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial EJOpen Bottom LlManteca Dia. of Well Excavation Dia- of Well Casing �q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications {. ["1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout t i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done .�C Type of Pump SL-0 H.P. State Work Done 7L G��l OUr'i 1 " Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 . 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Ins ion will serve: Residence_ Commercial_ Other ¢ Number of�sioil Number of bedrooms Character o �depth of Water table depth SEPTIC TANType/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ ' ��- Method of Disposal Distance to nearest: Well Foundation _Property Line LEACHING LINE LI No'. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property.Line SEEPAGE PITS I i Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line y 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 th San Joa n Local Health District. Home owner or licen a 'a nt's sigptur certifies a following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person i s ch nner s to eco ubiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ' certifies the followin I c rti y that in th pe rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- FJ tion laws of Califor is ' The applicant m t 11 f I quire ins s. Complete drawing on reverse side. Signed X ( Titlq:. - /�� ✓�_ Date- �/y 9,7 f9R DEPARTMENT USE ONLY F1 Application Accepted by r Data Are Pit or Grout Inspection by / Date Final Inspection b � r Date Fi TAdditional Comments: F_; L1St466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 171Tracy 835-6385Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 P *- ��---� � -f � '-5 '„ -.�._ r _w,sr`�ti e, -Cir �' l i s yar f� ,a ,�` 'w t•- s '4 1.r...to.. px� w•!��a b'�r" £';d 5} t t�n. T '6Ca'' -4 i _tt' ^y,,��r� A,a—w.��.• -u,.—:-.,w...r.......,.-,w.rx:....:A a +-1 rl*.ai 1-es.ss+d....•i..-�r.s.w..• sw.6r.a.. ,�....e.....,.w„v,.r .J..�Z..Kn :,k .'S. § a.l °- - . .s...--f_..+ �-..,Sw....A..-.....v....M-v..�?�r«..,..Awa'+s..a��...y:i..w-n.�,..�•a...ss».n..cwg.�k.-.,.t;+,l;s, �.�:.G�a+.viae-�s++�,ia-w# �,a','»_r�a.�ki�`