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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT jM IR- " 1601 E.`HAZEL t ON•AVE.,1STOCKTON, CA " = r� Telephone (209) a66-67$1 ,SUN 61988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` (Complete in Triplicate) F-101ROMENTAL HEALTH Application is heleby made to the San Joaquin Local Health District for a permit to construct and/or install the wolVERMI U§fltie l9 isSapplication 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. L Job Address �.1�aa ; "Q A Ora ZQ-AAW,-- City%C of Size PM or` Owner's Name ��`�Q s� AddressCID Phone -+02 17 444 ax— 73.37 Contractor,` "S�/`�* Address � M;�m:7 `Licerise No.149 23� Phone 41 TYPE OF WELL/PUMP: `-`NEW WELLAO' WELL REPLACEMENT ❑ `DESTRUCTION ❑` PUIi}0,INSTALLATION O, SYSTEM REPAIR ❑ OTHER l DISTANCE TO NEAREST:, SEPTIC TANK i SEWER LINES DISPOSAL,FLD. PROP. LINE -- tl Era r F,OUNDATION _AU`RICULTURE WELL OTHER WELL PITS/SUMPS _ 1 r INTENDED USE INPE QIs-WEhk4� `�jP_R.OBLEMAREA CONSTRUCTION SPECIFICATIOtNS ❑ Industrial ❑ Open BpitgM_� 'El Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ V'' Specifications 1`1 Public F Other 171 Delta Depth of Grout Seal � � Type of Grout I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done Type of Pump sL[� H.P. StatV1/ork bone _ Well Destruction ❑ Well Diameter Sealing Material (top 50'I ---- Depth Filler Material (Below 501 TYPE--OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION l 1. DESTRUCTION I I fNo septic system permitted if public sewer is ' _,.available_within 200 feet_),— �t Installation will serve: Residence_ Commercial_ Other �+ 4 Number of living units: Number of bedro'oms Character of soil to a depth of 3 feet: Water table depth f V' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ,f LEACHING LINE ❑ No. & Length of lines Total length/size }/ FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS € I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "! 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 follow( ify 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 C ornia." The applica must c for quired to draw' on rev side. Signed le: Q Date: / Fg"EPA,RT NT USE ONLY Application Accepted by Date _ o` Area ` ,7 ,i Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMtT'NO. INFO CASH + EH}3-24 ipEV.I/H 5) 3s g— EH 14-2e ►