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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1:� u 1601 E. HAZE I ON AVE., STOCICTON, CA Telephone (209) 466-6781 OCT 16 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAI.HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desCr94'r 46fiRVQE.&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, Job Address _ City Lot Size PM _ Owner's Name l� (A��ress Phone 2-2-z yam. Contractor License No. AddressR) /z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION VPWJO)1 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' 3omestic/Private ❑ Gravel Pack LJTracy Type of Casing Specifications f'1 Pubfic ❑ Other IA Delta Depth of Grout Seal Type of Grout — I I Irrigation __-Approx. Depth l I East rn Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done 'c2LI °C? y Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 �} t Depth Filler Material (Below 501 _ TYPE OF•SFPTIC WORK:, NEW INSTALLATION [1 REPAIR/ADDITION i I DE=STRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve, 'Residence— Commercial— Other 111 NumberY of living units: Number of bedrooms ' K Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑- ,Type/Mfg. Capacity No. Compartments PKG. TREATMENT PLT. ❑ k Method of Disposal (� Distance to nearest: Well * Foundation Property Line Q ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 whi this permit is issued,1 shall employ persons subject to workman's compensa- tion law Ca rnia." The al licant mu ca ttspa tions, Complete drawing r rse side. Signed Title: � Date: FOS D ARTMEN7 USE ONLY �� Application Accepte y Date Area Pit or Grout Inspection by Date Final Inspection by �- Date�� Y Additional Comments: r I ❑ 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 95201FEE j INFO AMOUNT DUE AMOU`N-T REMITTED CASH RECEIVED BY DATE PERMIT'NO. +.EH t3-24 iREV.Y/n 51 3 5 .�'L �ft ]�JQ EH .I