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i APPLICATION FOR PERMIT VE , SAN JOAQUIN LOCAL HEALTH DISTRICT KtCE 1 1601 E. HAZEL T ON AVE., STOCKTON, CA MAR 1990 Telephone (209) 466-6781 E� VIRONMEN AL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) PFRMlT�SER��tCES 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 I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. b Job Address Lot Size PM 1 Owner's Nam aW6 W, Add s .Y�.2� Phone J k 4fe Contractor r freS5 Y i"'License No.m&Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ a —DJ DI STANCE-T•0-NEAREST; SEP_TIC_TANK_ SEWER LINES __ .-.__^ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USES TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing XDomestic/Private Gravel Pack ❑ Tracy Type of Casing— Specifications 1`1 Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout _ � I I Irrigation —.Approx. Dept f I I Eastern Surface Seal Installed by. - Repair Work Done ❑ Type of Pump 9►V H.P. Sate " ork one Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') 1 — I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I Mo septic system permitted if public sewer is `available within 200 feet.) Installation will serve: Residence_ Co_mmercial Number of living units: Number er of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK []. Type/Mfg Capacity No- Compartments PKG. TREATMENT PLT-..El \\ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE _ ❑ No. & Length�of lines, I Total length/size LJ a FILTER BED . {Distance'to rsearest:, p'1NeN Foundation Property Line A: r. } SEEPAGE PITS i I Depth t �. •Size " f Number SUMPS Ll Distance to nearest: .1/—Well'^"" `" Foundation- Property Line DISPOSAL PONDS ❑ r _ _ hereby certify that I hav\e prepared'this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, and- rules and regulations of the..San'Joaquin Local Health DiMrict. I I Home owner or licensed agant's signature certifies the following: "I certify that in the performance of t,ie 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 laws of California." The applicant lust call for squired inspections. Complete drawing on re rse side. Sign Title: - + ' 1 Date: FOR DEPART ENT USE ONLY --^ Application Accepted by Date `� Area 2� Pit or Grout Inspection by Date Final Inspection by T Da r Additional Comments: If Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-&-45' I 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 CASH RECEIVED BY DATE PERMIT-NO. I INFO ♦.EH 13-24(REV.i/A 5) 't� 19 EH 14-2a