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I r UUfrr `^3 r. S APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT EL T ON AVE.,1611 E. HAZ STOCKTON, CA Telephone (209) 466-6781 MAR 2 9 1989 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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, Job Address City of Size PM i Owner's Name Address Phone Contractor dress rf Icense No.=0_—Phone TYPE OF WELLIPUMP: NEW W L ®—� WELL REPLACEMENT DESTRUCTION ❑ . . ----YPt1MP-iN5TAtLATON-®� SYSTEM REPAIR-0. OTHER--0 —�- — - DISTANCE-'O NEAREST: SEPTIC TANK SEWER LINES _6QJ9�._ DISPOSAL FLD. /PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL ! PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S ❑ Ind trial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack CD Tracy Type of Casing Specifications 11 Public ❑ Other r Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. De�p�th��/l I Eastern Surface Seal Installed by r Repair Work Done 17 Type of Pump �1J(�t7^a H.P. I State Work Done V1 Well Destruction ❑ Well Diameter Sealing'Material (top 501 LA Depth 2!�;A_U _ Filler Material (Below 50') ; V! TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet./ f Installation will serve: Residence— Commercial_ Other. Number of living units: I Number of bedrooms ' Water table depth r Character of soil to a depth of 3 feet: War 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: Well Foundation Property Line M SEEPAGE PITS l I Depth Size Number --SUMPS 4 I-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �^ .t• r' 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st all for all q red i pections. Complete drawing on re rse side. * g Signed X Title: Date: R F DEP RTMENT USE ONLY Application Accepted by Date T� Area / Pit or Grout Inspection by ate Final Inspection b� 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 FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT No. INFO CASE{ +.EH 13-24(REV.1/9 5) EH 14-26 i