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APPLICATION FOR PERMIT r� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 MAY 2 2 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMIT/SER%J� Application is herebiy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TFi application is made in compliance'with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin Local Health District. ifC `l / cityq!1^10CiQ Lot Size PM Job Address iv ��/ L J lQ f'1 GC �, Address f `� L� �` 'e ¢� Owner's Name �4•P_, phone fl_ "1— Contractor C�l $� Address 4et4 License No.2212p,-_�k_— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION, PUMP INSTALLA ION SYSTE REPAIR ❑ OTHE� ❑ DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES _ DISPOSAL FLO. / / PROP. LINE -,.. — , FOUNDATION - - -AGRICULTURE WELL� Q7_HER__WELL- . PITS/SUMPS . . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATICJVS P ❑ Industrial ❑ Qpen Bottom anieca Dia. of Well Excavat. n Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications (f I public Ll Other Cl Delta Depth of Grout Seal Fyyr-1 Type of Grout I I Irrigation ._Approx. Depth I I Eastern Surface Seal Installed by [1 G✓(ifP� _ Repair Work Done `❑ Type of Pump_ H.P. St to Work Done Well Destruction $� Well Diameter Sealing Material (top 5we 0') Depth Filler Material (Below 501 C e k4 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION iJ DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other f Number of living units: Number of bedrooms Jr Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg-'' Capacity No. Compartments }, PKG. TREATMENT PLT. ❑ Method of Disposal [[[JJJ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line -DIST CSAL_PONDS `❑__ hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, ander rules and regulations of the San Joaquin Local Health District. l 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 which this permit is issued, I shall employ persons subject to workman's compensa- tion lawsof Calif The applica must call far I req d ' spections. Complete drawing on r arse sid . Signed X Title: Data: �u F EPARTMENT USE ONLY Application Accepted by - Data � Area k. Pit Grout I spection by i e a` oFinal Inspection by Date ` a Additional Comments: Q ❑ 5tk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-714racy 835-6385 4)J f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S�� /Z �y1��'J�GGE9 'e a INFO FEEK AMOUNT DUE AMOUNT REMITTED CD ASH RECEI DATE PERMIT'NO. t +.EH 13-24 IgEV.5/H 55 - ' 1 1429