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APPLICATION FOR PERMIT w J SAN JOAQUIN LOCAL. HEALTH DISTRICT `F 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JUN APERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 8 1990 (Complete in Triplicate) ENVIRONMENTAL HEALTH � ,�I!•'RLr'2TrY MJRig� made in o is hetbye �theSanOrdi[Locanance No. 549 for sewage orealth District for a 't to No. 1862 forct and/or install the well//pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin'County O Local Health District. 4PAI ,77—�fO—Al l le i"01-111B It'.S� C6P G # �"�fu f rP1(e' City S CiK� Lot Size it/7s/�7R PPM Job Address ret r c r Z Owner's NameyvrlllRm Co Address Phone Contractor SpE[ V y Address.Z dZ�E/'� ►' e'�{• License No.� Phone_ �3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ f�T � Eod�NGS PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERion /ori If DISTANCE TO NEAAST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIN &it FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C1 Manteca - Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications F1 Other 1 1 Delta Depth of Grout Seal Type of Grout p F� Public A61m, •4 spy I`761E3 ,Sur _ _C r I I Irrigation —.-Approx.;Depth I I Eastern Surface Seal Installo y UJIL-4- ri3.�QCrAi-/LL W� Repair Work Done ❑ Type of Pump H.P. State Work Done _- � P� /SiF w Well Destruction ❑ Well Diameter Sealing Material ltop 56'1 f g Depth Filler Material 16elow 501 E�Ieou�T TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is III t available within 200 feet.] Installation will serve: Residence I Commercial— Other Number of living units: Number of.bedrooms + Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number r SUMPS ❑ Distance to nearest: Well Foundation Property Line 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 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 co for all required ' cti n . Complete drawing on reverse side. Signed X f Title: ?rOfe� tG Bre' Date: FOEPARTMENT U5E ONLY Date Area r2&S Application Accepted by Pit or Grout Inspection by Date Final Inspection by Date l Additional Comments: ❑ Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20091 Stk., CA 95201 I 7FFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DrATEPERMIT'NO. ♦ EH 13-24 IAM I/n al U Ic?() r l 77q EH 1426 I