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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA I 1` E C E I'VE mu Telephone (209) 466-6781 NOV 6 1989 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (Complete in Triplicate) NVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the woRQXIISWwETQ; Iication 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 z �5 City &44/7Lot Size PM Owner's Name Address Phone 4 Contractor �� Address2/0_ License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION _AGRICULTURE WELL _ _ OTHER WELL - __ PITSISUWS -_ f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r I` ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7omestic/Private ElGravel Pack El Tracy Type of Casing Specifications F1 Public f7 Other T— 1-Delta Depth of Grout Seaf Type of Grout I I Irrigation Approx. Depth A I 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Don,Z/'ISAl1C'LI -�iJ1F� Well Destruction ❑ Well Diameter Sealing-Material itop:50'1�� } _� __.._.. Depth _Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION II REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_'"""Commercial_ Othef r Number of living units: Number ofFbedrooms ! Character of soil to a depth of 3 feet:--� -- s Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ _., l Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size `I FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I 1 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line a Y , 4 DISPOSAL PONDS ._ ❑ . - T 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 Di§trict. 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 w tc is permit is issued, I shall employ persons subject to workman's compensa- tion law ifornia." The ap licant m st call f u' d inspections. Complete drawing o se side. Ll--'(v Signed X Title: Date: DEPARTMENT USE ONLY Application Accepted by Date L / Area Pit or Grout Inspection by y..D_to Final_Enspection byDatel �`� 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 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED] CK' RECEIVED BY DATE PERMIT'No. INFO CASH r' pG +.EH 1324)REV.l/x 5) 3.!; C )1-7 11-!� X;23 £H f4-26 I