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- R k. E] r A�•w- I APPLICATION FOR PERMIT ",E SAN JOAQUIN LOCAL HEALTH DISTRICT . i 1601 E. HAZELTON AVE., STOCKTON, CA APR 2 4 M.901 Telephone (209) 466-6781 EWRONMEN T AL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) `1�,1 Application is hekeby 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 welUpump and the Rules and Regulations of the San Joaquin I Local Health District. Job Addrefk6 1 0 E Col l i e R O ii City A C 0 _ Lot Size PM Owner's Name Address 6610 E . Co 11 i er Rd . Phone Contractor Ci]1211r1 AddresS17754 N. HWY. ffi, LOCkeford License No.309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ FDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F _ FOUlVD9TI_pN_� _AGRICULTURE WELD _OTNFR WELL _PITSIS0WS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial _ ❑ Open.-Bottom _ -_❑ Manteca Dia. of Well-Excavation Dia. of Well Casing ❑ Domestic/Private -0_Gravei_Pack -_, a D,Tracy �i Type of Casing Specifications f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout __ i �.-- I 1 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ e Repair Work Done 11 Type of Pump Turb Z fl M-P. 30 State Work Done Repaired Pum _ p �- Well Destruction ❑ Well Diameterx Sealing Materia! (top 501 Depth Filler Material (Below 50'1"- — L� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION l I INo septtklablewthin system permitted it public sewer is Installation will serve: Residence Commercial Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No- Compartments y u PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i k LEACHING LINE ❑ No. & Length of lines T Total length/size FILTER BED ❑ Distance to nearest: Well —Foundation Property Line SEEPAGE PITS t I Depth Size Number SUMPS _ L-1 Distance to nearest: Wel! —Foundation Property Line DISPOISPO O NDS�-Q • - '� �' _ _ - - 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 age is 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 suc annex as to become subject to workman's compensation laws of California-" Contractor's hiring or sub-contracting signature certifies the followin c ify that s the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor ' The applicant r all equired inspections. Complete drawing on reverse side. f Title: Bk r. Date: 4122/91 f Signed X FOR DEPARTMENT USE ONLY Application Accepted by Date Area `2 t Pit or Grout Inspection by Date Final Inspection b Date �J j Additional Comments: ! ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 AINOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER NO. I INFO +.EH 13-24(REV.k n 6, •� �r� � EH 14-28 1 k r