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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT .: , VLLI 1601 E. HAZELTON AVE., STOCKTON, CA s Telephone (209) 466-6781 0 4T 1 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENV! ,,. i ,,...NTAL HEALTH (Complete in Triplicate) PLDRvo,i f/"SERV1i1;ES 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. =a Job Address dd 0 1,J City Lat Size PM L -dr Lttt� Address PhoneOwner's Name ` lJrn Contractor Address 7!P0%I icense No. PhoneQJ-+' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Com' SYSTEM REPAIR A--� 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing RL mmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public 17 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Easternrface Seal Installed by Repair Work Done L`3Type of Pump ,.61_1�= H.P.`3 �uState Work Done Well Destruction ElWell Diameter Sealing M terial Itop 50'1 Depth . filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (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 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 FILTER BED C7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 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, rules and regulations of the San Joaquin Local Health Di§trict. 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 pertormance of the work for which tit is permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant c I for all regi it inspections. Complete drawing on r verse side. d Signed Title: Date: F DEPARTMENT USE ONLY v r/ Application Accepted by Date / Area .2`b Pit or Grout Inspection by Date Final Inspection by Date�C) 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 95241 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMIT'NO. +.EH1 -241RFV.riK5) EN 14-28 .47