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APPLICATION FOR PERMIT iN �� SAN JOAQUIN LOCAL HEALTH DISTRICT APIA 2 6 1989 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH 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. Job Address # 1_ z.O City JLot Size PM Owner's Name Address �- � Phone f ContractarPgYseT - Address 536License hfo. 7 6-2- Phone TYPE OF WFLL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL "� "PITSISL1f1APS+ "� "� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth l 1 Easter Surface Seal Installed by Repair Work Done Type of Pump-4--1— H.P. 41A.4., State Work Done Well Destruction Q Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l7 REPAIR IADDITION I l DESTRUCTION I 1 1No septic system permitted if public sewer is available within 200 feet.) 1 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 01) SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _ •--c- '�. ,,....-. _ ��. -�_. 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 District. Home owner or licensed agent's signature certifies the following: 41 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 subject to workman's compensa- tion laws of California." The applicant must caU for all required inspections. Complete drawing on verse side. Signed :Title: Date:'2 7t2 FOR DEPARTMENT USE ONLY 1If Application Accept d by __ r Date q-24-4 Area Pit or Grout Inspection by Datel Final Inspection tveL Date C Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /NFD AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT*NO. ♦.EH13-24(REV.1/H 51 ��j EH 14.28c2t V199 1 } I