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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA D "� Telephone {2091 466-6781 u n PERMIT EXPIRES 1-YEAR FROM DATE ISSU U (Complete in Triplicate) OCT 01989 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 V" Rqt"Lat TA the San Joaquin Local Health Distriict. PERMIT 1 SERVICES Job Address 17334= = hi Uy f.11y 7Kr City Lot Size PM 'S eOwner's Name �� / ,o — Address Phone A D tD t ? r f`'z ��9Y1 Phone 4 8'313 P Contractor Address �+ icense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L*& SYSTEM REPAIR ❑ OTHER ❑ DISTANCE= TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA - CONSTRUCTION_SPECIFICATIOfVS_ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 17 Other n Delta Depth of Grout Seal Type of Grout _ 1x!Irrigation Approx. Depth l.] Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 14 H.P. 7Q NJ State Work Done, T• Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material I8elow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I:l REPAIR/ADDITION f 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 feet: Water table depth c— 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 �. SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ 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 m T 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 rn st call all required inspections. Complete drawing on reverse side. Signed Title: Date: i f J� FO ARTMENT US ONLY � '12� Zlw - w Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Dated 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 2005, Stk., CA 95201 FEEINFO AMOUNT DUE AMODUNvT�REMITTED GASH 11 RECEIVED BY DATE PERMIT-NO. +.EH 13-24 INEV. "M �� t 1.b'01 " �''t EH 14-29 ✓ �/ J