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?w' APPLICATION FOR PERMIT RECOMNED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA NOV 10 1989 Telephone (209) 466-6781 ENVIRONMENTAL HE LTi-4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 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. 5 , Job Address City N/ Lot Size PM Owner's Name �1fLefldress 404-",^e Phone Contractorj _D'-si- ;✓.7-,--CkC)r,_Address t� f'> A r.� License No.�_ Phone TYPE OF WELL/PUMP: NEW WELL'❑ ` WELL REPLACEMENT ElDESTRUCTION ❑ PUMP INSTALLATION • �� SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.' PROP. LINE FOUND'ATION'S °'AGRICULTURE WELL.- OTHER WELL--- _PITS/SUMPS-_ r� - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing - ><Domestic/Private -❑ Gravel Pack ❑ Tracy Type of Casing Specifications r Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth l 1 Eastern / urface Seal Installed by Repair Work Done ❑ Type of Pump -_ H.P. State Work D}ne�S ti� T- ff LP- Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l )' DESTRUCTION I i INo septic system permitted if public sewer is *I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other R A�/ �� Number of living units: Number of bedrooms "► .._�. � Character of soil to a depth of 3 feet: F at�1>lNl�" SEPTIC TANK- 0-Type/Mfg Capacity(9fa is PKG. TREATMENT PLT. F] SAN jogWlof D1#3al Distance•fo nearest: Well Foundation 1 ERI-P, C , 1f Vr Y! €o �tc7y ory � LEACHING LINE y ❑ No. & Length of lines �•� Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line x SEEPAGE PITS I I Depth Size. "'" "' _ Number ' .SUMPS _ YL-1 Distance to nearest: .. Well - Foundation " t Property Line DISPOSAL PONDS ❑ -Distance-to 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 st-call for-all reqUkoo in ions Complete drawing on re e side, Signed X Title: �� . .,..",...,__ Date: cF9R DEPARTMENT USE ONLY i Application Accepted by f date ��I Aran _ 1 Pit or Grout Inspection by Date Final Inspection by Date/ Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 ❑ Tracy 835-6385 F 11 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 CASH RECEIVED BY DATE PERMIT"NO. + EH 13-21(REV.1/N5) b EH 11-28 � � 'I� 1`t sn":u s-4