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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAYS,$ 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY � PUBLI HEAL I tc�c Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insEM" n VWw plication is made in compliance with San Joaquin County Ordinance�No.549 for sewage or No. 11362 for well/pump and the u e IIII r�r1>rils�&Joaquin Local Health District. l,lf ( I 139- 090 -02-- Job 3 q- ©90 _Q2 �Af7v � PM Job Address I Lot Size Owner's Name a tP!+V AL�� W�-e-4- __ Address tAIPhone 3955-23usfness !I 6Z_ 68a 9 Contractors Address 1s/+J License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEF, 6i t ll LAOS Pfok DISTANCE TO NEAREST: SEPTIC TANK �r� SEWER LINES DISPOSAL FLO. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I I 11Industrial ElOpen Bottom C) Manteca Dia. of Well Excavation Dia. of W II Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing tr Specifications i"1 Public Cl Other fl Delta Depth of Grout Seal '"�� Type of Grout��_ rt8 _-. I I Irrigation __.-Approx. Depth I I Eastern Surface Seal Installed by �M _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ( I DESTRUCTION I 1 INo 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 ` 1 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 �M O FILTER BED ❑ Distance to nearest: Well Foundation Property Line �M SEEPAGE PITS I 1 Depth Size Number �M SUMPS Ll Distance to nearest: Well Foundation Property Line JI. DISPOSAL PONDS ❑ �M I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 11 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 orisub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjectk to workman's compensa- tion laws of California." i! The applica t fmust call f r I required inspections. Complete drawing on revers side. Signed X �LCiN-h Title: ® Date: &/ F EP NT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection i Dates�—F& Additional Comments: I" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I C SH RECEIVED BY DATE PERMIT'NO. INFO + EH 13-241REV.r/rt sl �sl �r+L4� i0-J? k/J EH 14-211 GO