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APPLICATION FOR PERMIT G SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E. HAZELTON AVE., STOCKTON, CA RAC MINT Telephone (209) 466-6781 e l V e D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 19 1988 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install hre1wf a plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R �� an Joaquin Local Health District. S Job Address Ci / of Size PM Owner's Name• Address Atepho Contractor Address > � Phor f3lAnse No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION CTS SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 2'5o`mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ----Approx. Dept Eastern SurfAe Seal Installed by ` Repair Work Done ❑ Type of Pump H.P. // a- State Work Done ' a C Well Destruction ❑ Well Diameter Sealing Material (top 50'} '— Depth Filler Material (Below 501 fn 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: 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No: & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C7 a. A 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."Contractors 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 subiect to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. r� Signed X1, Title: e � Z� Date:L FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546386 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED 113q-3 CASH 4 RECEIVED BY DATE PERMIT'NO. + EH 13-24(REV.�/85) 3 3(S . � _ EH 14-26