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i ! APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ^ 14#4r, i 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 f 1 PERMIT EXPIRES TYEAR FROM DATE ISSUED' JUN 17 1987 (Complete in Triplicate) MOMENT L HEALTH n g ',Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo � + ilr �ication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules.a t Joaquin Local Health District. =r t g �Y ' - . City Lot Size PM I Job Address Owner's Namel?41ylc &04&S Address /4`• Phone M I Address � License ' Contractor I '" "TYPE OF WELL/PUMP: . ,;i. NEW WELL ❑- ^•�- —WELL REPLAC ENT IJ DESTRUCTION ❑ PUMP INSTALLATION,AL 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 [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ;Domestic/Private ❑;Gravel Pack ❑ Tracy Type of Casing Specifications 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth I Eastern Surface Seal Installed by - } - k -Repair Work Done ❑ Ty'pe of Pump / H.P.• State Work Done _ F✓ ! Well Destruction El Well Diameter _ r Sealing Material Itop 50') ! Depth /Jai Filler Material (Below 50') t TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION {.1 DESTRUCTION I I (No septic system permitted if public sewer is II f available within 200 feet.) �. Installation will serve: -Residence_ Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑'Ii-Type/Mfg J Capacity No. Compartments t F`- .; PKG. TREATMENT�PLT. ❑ Method of Disposal u Distance to nearest: Well w Foundation Property Line LEACHING LINE - ❑ No. & Length df lines Tota! length/size FILTER BED •❑ ! Distance to nearest: ;Well Foundation Property Line SEEPAGE PITS k I ii Depth R _ Size _ Number SUMPS ❑I Distance to nearest: I Well Foundation Property Line (�- DISPOSA&PONDS"""❑ - I hereby certify that I have prepared this appli±ation;`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 ceriffies t6 following: "I certify that in the performance of the work for which this permit is issued, i shall not w 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 must c 11 f r rll r quir ctions. yomplete drawing on reverse si 1 5 Signed X Title: ___..._...� ��'� Date: 6 /00F IFOR DEPARTMENT USE ONLY r Application Accepted by Date Y nil) Area 11 {' 1 ' pection by _ Pit or Grout Inspection Date Final Ins + Date • �.. .. a. �^-�•-^�Additional-Eomments: ❑ 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 2009, Stk., CA 95201 CK It hh . I FEE AMOUNT DUE„ AMOUNT REMITTED 1 RECEIVED BY DATE PERMIT NO. INFO42 CASH + EH 13-241REV.i/H5) 4 • - 16-/747 EH 14-2a