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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ;APR lo 1990 PERMIT EXPIRES TYEAR FROM DATE ISSUED 4 (Complete in Triplicate) NVIRONMENTA HEa, JR4 ApP�ogg1 e the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is i made rn San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. {{�� Job Address Z'2_ I'�tJ�� ' City Lot Size PM Phone Owner's Name �—l�uL Address �1 L rrzt r� rez.•�r - Cs7-Y 3� p i Contractor Address � License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / El Industrial LJ Open Bottom 11 Manteca Dia. of'Well Excavation Dia. of Well Casing r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications „L_ �Y � ' C /� f'1 Public .ree�Other ❑ Delta Depth of Grout Seal Type of Grout A rax. Depth I 1 Eastern Surface Seal Installed by r - I 1 Irrigation �� PP P Repair Work Done ❑ Type of Pump H.P. State Work Done_ a 191%J In ZA P e. Well Destruction ❑. Well Diameter Sealing Material ftop 50'1 Depth Filler Material jBelow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial__ Other r t Number of living units: Number of bedrooms Character of soil to a deptp of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS I.l Depth Size _ Number fSUMPS D Distance to nearest: Well Foundation Property Line 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 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, 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,1 shall employ persons subject to workman's compensa- I tion-laws of California." The applicant ail fo I required inspections. Complete drawing on reverse side. Signed X Title: ��5! -tom Date: l� �/J� r' «( f7ilcSzlN OR DEPARTMENT USE ONLY /3 -� Application Accepted by Date d Area Pit Grout nspection by \ \ o Date ,()Final Inspection by Date eke ram [5%a ,li i Ie Additional Comments: ❑ Silk 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 95201 IFEE NFO (AMOUNT DUE` AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24 IAEV.�/H 5� I S t /cta —947 EH 14-29