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w I APPLICATION FOR PERMIT SAN JOAQUINLOCAL.HEALTH,.DISTRICT• R E C E I V Em D 1601 E. HAZE T ON AVE., STOCKTON, CA —Telephone (209) 466-6781., J U L 17 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH II (Complete in Triplicate) PERMIT/SERVICES 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. II ri J Job Address 1 d S City Lot Size PM r .. L ) Owner's Name ,06��1 �D t1 L Address Wak Phone .I` Contractor I Address I , � 01c� License No. �S,742.1Phane i TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ I PUMP-INSTALLATION-El -_- - SYSTEM REPAIR OTHER ❑ DISTANCE:TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIION AGRICULTURE WELL OTHER WELL PITS/SUMP,$ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t6*V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation tbia�of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications�... \ Fl Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout' I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by _ 2r Repair Work Done 0 Type of Pump t,:5!Z i H.P. � _— State Work Done � n Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Az Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permifted if public sewer is available within 200 feet.I Installation will serve: Residence E Commercial_ Other 1 Number of living units: Number of bedrooms Character,of soil to a depth of 3 feet: - Water table depth I O SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments + PKG. TREATMENT PLT. ❑ i ' Method of Disposal I Distance to nearest: Well Foundation Property Line' LEACHING LINE ❑ No. & Length of lines Total.length/size FILTER BED ❑ Distancelto nearest: Well Foundation Property Line a � a SEEPAGE PITS I 1 Depth Size 'Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I herebycertify that I have re ared th ~�`- 'y p'p 'is application and that the work wil(be done in accordance with Sari Joaquin county ordinances; state laws, ani rules and regulations of the San Joaquin Local Health District. `r 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 follow : "!certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calit mi .' i The applican u call for all requir inspection . Complete drawing o r rse sid iI �„ 1 Signed X 3 _Title: Date:- — 2-1DEPARTM T US ONLY I _ Application-Accepted by Date f Area Pit or Grouf'fnspection Data Final Inspection by J Data Additional Comments: I L1 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 95.201 d .-- AMOUNT REMITTED DATE'CK 'RECEIVED BY " ' PERMIT'NO. INFO AMOiJNT DUE GASH �,1�,� EH 13-21(REV.1/K 65 � z O�c 7 /f 7 EH 14-26