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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT R4 E('0;4' ohm I VE D 1601 E. HAZE i ON AVE., STOCKTON, CA AUG 2 2 1990 Telephone (209) 456-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the San Joamquin Local Health District for a permit to construct and/or install the work herein described. This application is Applicanty Ordinance No.549 for sewage or No. 1862 for wewpup and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin Cou Local Health District. City Lot Size PM Job Address Phone Address Owner's Name 1 License No. � one Contractor Address TYPE OF WELLIPUMP: ._NEW WELL.❑-------•--�4"P_L- CEMENT DESTRUCTION ❑ SYSTEM REPAIR ' OTHER ❑ PUMP INSTALLATION ❑ f PROP. LINE SEWER LINES DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK l FOUNDATION AGRICULTURE WELL z OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing i 11 Industrial ❑ Open Bottom ❑.Manteca" Dia- of Well Excavation Specifications DomeiticPrivate ❑ Gravel Pack ❑ Tracy f. S Type of Casing k IV ft' Other ❑ Delta,\:. • Depth of Grout Seal Type of Grout E Public I I Irrigation ��Approx.-Depth t I,Eastern Surface Seal Installed by '�. / H P _ State Work Done Repair Work Done ❑ Type of Pump —1 r- Sealing Material Itop 50'.1 vJ Wet1_Destruct_io_n�,•,._❑-...�We11.Diameter �, f pepth z Filler Material I Relow 501 r TYPE OF SEPTIC WORK: NEW INSTALLATION-) —REPAIRIAQDITION-1 I'—QEST RUCTION l I anvailablelc sYs�tem within 200 feet.) if public sewer is Installation will serve: Residence_ Commercial-=�=_—Other----�-------�•^^�—"•�� Numb r;of living units: Number of bedrooms , * -f Water table depth Character of soil to a depth of 3 feet: . j No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Z Method of Disposal PKG. TREATMENT PLT. d d Property Lines Distance to nearest: Well Foundation r Total length/size LEACHING LINE CI No. & Length of lines Property Line 4 - Foundation FILTER BED ❑ Distance-to nearest: Well } III Depth y �t Size �Number •y_ t SEEPAGE PITS l I Qep Property Line SUMPS �7 0 Distance to nearest: Well ' Foundation e DISPOSAL PONDS ❑ - 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 i rules and regulations of the San Joaquin Local Health-District---�-- _-- —^ 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,.1 shall not employ any perso•n such manner as to become subject to workman's compensation laws of California." Contractor's hiring subject t wo�kman`�scompensa i certifies the,foll in "I certify that in the performance of the work for which this permit is issued,1 shall employ p I do aws 0 omi _ F The applic call for all re uir d inspect' n . Complete drawing on ev s side r Title: Date: • Signe�-X" k R IJEPARTIIA USE ONL k .., Date �� Area ,4pptication Accepted by J (� ;. - Final Inspection b� �} —�� Date `Pit or Grout Inspection by Date t' i Additional Comments: LJ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av}., P.O. Box 2009, Stk., CA 95201 i CK RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH i INFO l / �q l I + EH 1 -24 IREV.1/95) EH 14-26 f s 1'