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y APPLICATION FOR PERMIT RECEIVEV.SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 0 CT 1 8 1990 { Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES TYEAR FROM DATE ISSUED PERMIT/SERVICES (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. k i Jab Address City of Size PM � Go � Owner's Name Address tj Phone / i Gontracto� "' Address _ _ _. Tom' 4 t License"fVa. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ -DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES ---- — .DISPOSAL FLD:— -_.MPflOP..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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump .--_5:WA H.P. State Work Done _ IA-re U Well Destruction C] Wel! Diameter -. Sealing Material (top 501 E y Depth ' V Filler Material (Below 50') + ^►- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION !fl (No septic system permitted it public sewer is 'y mailable within 200 feet.) Installation will serve: Residence-- Commercial_I Other �n 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:w Well Foundation Property Line I , 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 L'1�'Distance to nearest: Wel!"� — Foundation Property Line -------------- DISPOSAL FONDS ❑�""�"""� - '- - k 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 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: ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to-workman's'compensa- 4 tion law$of Californi { The applicant ! for all required ' pections. mplete drawing on re er si e. f p n !! Signed X Title: ' Date: /C�Y�S �_ F V` FOR DEPARTMENIVUSE ONLY I _ ! Application Accepted by Date !t� Area Pit or Grout Inspection by Date Final Inspection by Date_ZO — I Additional Comments: r f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ ManteEa .8T3-7104 0 Tracy 835-63135 Applicant`- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'N0. + EK 3-24 EH 1.4-2e!REV.t n 51 fV1- UR�_` �C)_ORDB IL- �