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r V APPLICATION FOR PERMIT I�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �,I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i rvTAl. HEALTH (Complete in Triplicate) Gr /SERVICES c f,„ sERM1T Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work f1rein 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 Local Health District. :t Job Address IJJ ,�' R�� City - •' - Lot Size PM Owner's Name i L -- -- Address _ Phone �L!r Contractor c.�Q �I� Addres �- License No. 1 �_Phone _ TYPE OF WELL/PUMP: NEW WELL?4 WELL REPLACEMENT; DESTRUCTION ❑ PUMP INSTALLATJON�❑ f SYSTEM REPAIR ElOTHE�i ❑ 5761-3 we DISTANCE TO NEAREST: SEPTIC TANK 11` '' SEWER LINES DISPOSAL FLD_ .PP PROP. LINE F,IOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 'TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIO�15 i G Industrial O Open Bottom 0�tManteca Dia- of Well Excavatiow_ Ulf Dia. of Well Casing Domestic/Private Gravel Pack racy Type of Casing &, - Specifications 0 f0cl 1017 F1 Public ther ff❑ Delta Depth of Grout Seal - Ilq Type of Grout 8--e RAAA26? ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed bye(-'?�-- Repair Work Done n Type of Pump __ H.P. State Work pone (1 Well Destruction J Well Diameter ~ Sealing Material {top 501 _ ?� Depth _ Filler Material Melow 50'l — 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: Il Number of bedrooms Character of soil to a depth of 3 feet: _ —Water table depth SEPTIC TANK ❑' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - I Distance to nearest: Well Foundation___ Prop I ` Total len th/size AUG 3 0 1988 (� LEACHING LINE Lr No. & Length of lines 9 ,� C¢ FILTER BED 0 Distance to nearest: Well Foundation Property Line FNVIRf1AeCnrYn1 ur.erTH < SEEPAGE PITS 0� Depth _ Size Number FERnlT/SERVIOES SUMPS ❑ Distance to nearest: Well Foundation - Property Line --DISPOSAL PONDS-4-8!— I ONDS-4-8! -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. 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 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 m II forl,a r ire inspections. Complete drawing on rev side. L Signed X__ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 7�Area Pit or Grout Inspection byll. Data �� Final Inspection byi Date Additional Comments: 0 U' ❑ Stk 466-6781 ❑:,Lodi 369-362J1 ❑ Manteca 623-7104 ❑ TraW 835-6385 Applicant - Ratum al copies to: Environmental Health Perm' / ervices 1601 E. HazeVqn Ave., P.O. B 3x 2009, Stk., CA 1 ! FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. - R INFO Vi +EH13-26 IREV.i/R5) tw EH U-26