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" APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JON 2 2 1990 PERMIT EXPIRES '€ YEAR FROM DATE ISSUE! NVIRONMENTAL HEALTH (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. y� Job Address • , L'CG� City '-- Lot Size PM f Owner's Name .f dlu 0(, Address © ` ✓t om✓�"` '� Phone , s� 7 _ Contractor 1 �f�.� �- iAddress 1 {� o. _.(,t ��Cicense NoS9 � 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 116omestic/Private ❑ Gravel Pack' ' " t❑ Tracy Type of Casing Specifications 1-1 Public E] Other, fl Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. DepthI 1 Eastern N, ySurface Seal Installed by _ �.- 1Repair Work Done C7 Type of Pump-�� H.f. .�^�"' State Work Done °� L?✓s-r:�j Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 'Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_____ Other Number of living units: Number of bedrooms r Dc1 Character of soil to a depth 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 L/ FILTER BED ❑•- Distance to nearest: Well Foundation Property Line " SEEPAGE PITS I I Depth °' �'` Size Number SUMPS 0 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, rules and regulations of the San Joaquin Local Health bi'sfrict` - -� 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-contfacting 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 must 9aH or all required inspections. Complete drawing on reverse side. Q Signed X Title: .�f .�. Date: F EPARTMENT USE ONLY 7 Application Accepted by Date Area ;Z/,* Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ 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 95201 �u IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ![�j +.EH 13-24 4REV.r i x 51 �/ O`I EH 14-26 �. f