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s� J APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 2-5— ok'lvli-0 2— 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 n ' made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. UQ %A) � d � � PM ' CLITu 7Q TTN = Set ]UjRP City Lot Size Job Address SAN American services 505 Community sane Woodland Ca. 95695 Owner's Name Address Phone f)dllra ' License Contract Address Nu. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ^° a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 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 ❑ Tracy Type of Casing Specifications ❑ Public n Other n Delta Depth of Grout Seal Type of Grout I I irrigation —..Approx. Depth I I Eastern Surface Seal Installed by --- ' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material atop 501 ee Attachment Depth 5' Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l I DESTRUCTION I ; (No septic system permitted,if public sewer is available within 200 feet.) Installation will e: Residence_ Commercial_ Other I; Number of living uni S. Number of bedrooms _ u ' Character of soil to a depth o feet: aler table depth SEPTIC TANK O Type/M C�ndatian _ aitNo. Compartments i1 PKG. TREATMENT PLT.❑ Method of Disposal ' Distance to nearest: oProperty Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance ton st: Well Foundation Property Line 1 SEEPAGE PITS epth Size Number _ SUMPS 0 Distance to nearest: Well _ Foundation Property ' DISPOSAL PONDS ❑ 1 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, 6 shall not ' employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies th in?: "I certify th performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion la of Califs ia." Thea licant mus calif o' tl squired i ctions. Complete drawing on reverse side. Signed X 11 1Tule: Perimit Agent Date: Sept. 28 x.988 FOR DEPARTMENT USE ONLY Application Accepted by ` Date 41 �o Area ' Pit or Grout inspection by Dat® Final Inspection by Date Additional Comments: ---�� ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' :Applicant- Return all copies 10; Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009, Stk., CA 95201 �I �� j FEE AMOUNT DUES AMOUNT REMITTED QED CASH l RECEIVED BY DATE f ERMIT•NO. K INFO c c/�_ �C�� EH 13-24(REV.tins) 43 74,'b '88 Q5S I EH i9.2a