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y _ _APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 • 1601 E. HAZELTON AVE., STOCKTON, CAb Telephone (209) 466-6781 `�1 °galPERMIT EXPIRES 1 YEAR FRONT DATE ISSUED 1 ,JUIN 71989 (Complete in Triplicate) FK„ic, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work-her¢maesbiibedl7hisfaQpti tion is made in compliance with.San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulauons;8f,%%ilia"San 7' .quin Local Health District—, f -20 7o ' I11 �7� //,,� yy Job Address -y, 7 + City4&_A( J-Lot Size _ PM ..., Owner's Namal Addr€ss I�7- Phone Contractorr ss ,L7 y icense No 22z Phone R .� TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALI TION SYSTEM REP91fl ❑ O HER,0 DISTANCE TO NEAREST_: SEPTIC,.TAN0 .SEWER LINES : DISPOSAL FLD.�-PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A00 INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, i I� ❑ Industrial ❑ Open Bortom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy I Type of Casing t _ Specifications F] Pubic ❑ Other + Ll Delta Depth of Grout Seal - ype of Grout - ta «igarion AW—Approx. De t I I Eastern Surface Seal Installed In r _ Repair Work Done ❑ Type of Pump �.-7 !/ C H.P. State Work Dona_ I Well Destruction ❑ Well Diameter _lam Sealing Material ftop 501 i Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I I DESTRUCTION I I (No septic system permitted if public sewer is �` ? available within 200 feet-) V Installation will serve: Residence_ Commercial_ Other I ( Number of living units: — Number of bedrooms Character of soil to a depth of 3'fMi"'-"-' ^ - - Water table depth- SEPTIC TANK ❑ Type/Mfg _ _ Capacity No. Compartments �y PKG. TREATMENT PLT. ❑ .^ -�_ Method of Disposal I Distance to nearest: Well Foundation Property Line ! LEACHING LINE ❑ No. & Length of lines Total length/size U 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line r� ) _I,$EEP_AGE_PITS,,» tI Depth Size Number SUMPS - �❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 I hereby certify that 1 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 D1iltrict. Home owner or licensed agent's signature certifies the following: "I cerdfy that in the performance of the work for which this permit isissued,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contacting 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 workmen's compensa- tion laws of California." i The applicant mus' for all ruir nspe tions-Complete drawing on re side Signed X Trcle: �v . Dam: FOR DEPARTMENT USE ONLY .Application Accepts-d by /p iYLar�,� Data � Area I Pit or Grout Inspection by Date Final Inspection by- T'`T Date9"d Additional Comments: • O Stk 466-6781 , ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-M /(Applicant- Retum all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 f IFEE NFO AMOUNT DUE AMOUNT REMITTED CKA CASH RECEIVED eY DATE PERM VNO. +;:H t33�lREY,i+x51 /d�.Op I...za 1 8_ TQ H t4]e vV {