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- ✓j- �-. - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ff , �. 1601 E. HAZE I_ ON AVE., STt7CKTON, CA NOV 4 9 1988 Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) PE--IdMI'I 1 cIZ'Ji�;i 5 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 i ®0 J ` City � `�n Lot Size PM Owner's Name `�� 91Z C_ W�t1 Address Phone Lff~ Contractor /.4ri4LT4f" A& Address,Address License No. I�-�`Z Phone Z TYPE OF WELL/PUMP: NEW WELL_^ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT��IO�NN ❑. SYSTEM REPAIR C1 OTHER'' ❑ DISTANCE TO NEAREST: SEPTIC TANK k SEWER LINES DISPOSAL FLD.//�-PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WI=LL Lam -, PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICA I 16 a �/ yl-,PDublic dustrial E) Open Bottom 71 Manteca Dia. of Well Excavatio Dia. of Well Casing omestic/Private Gravel Pack L3 Tracy Type of Casing Specifications / d f� I.7 Other (-1 Delta Depth of Grout Seal Type of Grout /XP. Irrigation --Approx. Depth Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ 1' Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 50 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is 0 available within 200 feet.) G 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 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 lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line Y DISPOSAL PONDS ❑ m� 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in th rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Califor The applica ust ca forr it inspections. Complete drawing on rev se side. l 1 Signed Title: Date: Application Accepted by R D R ENT USE ONLY�7 Date � � Area Pit or Grout Inspection by Date__ r�" Final Inspection by 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 2409, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. *.EH 13-24{REV.t/As) EH 14-28