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APPLICATION FOR PERMIT SAN JOAO.UI'N LOCAL HEALTH DISTRICT PAYMENT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JUL 2 6 1989 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL H rrHEALT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thP6dbFk` PXKfKd. 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. Job Address 0210 — City / Lot Size PM Owner's Name Address Phone Contractor ddressse No. �%Phone C5 7 TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.140 1 PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a r Dia. of Well Casing Domestic/Private bd Gravel Pack Tracy Type of Casing do V'. Specifications , f'1 Public C_1 Other ❑ Delta Depth of Grout Seal /DO Type rout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _..- Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I_I 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 Number of living units: Number of bedrooms Character of soil to a depth of 3 teat: 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 ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS 171 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif rnia." The applic st call for all required O' Dections. Comp) a drawing on v rs si 7 �J Signed X it[e: Date: r R DEPART ENT USE ONLY ' r 7f Application Accepted by > Date Area -�> Pit or 00Inspection by asAf 0 Date ��0 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 EEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT NO. /� +.EH 13-24iREV.1/h5) �Q` 00 7a 06 EH 14-2e