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� I APPLICJTION'FOR PERMIT ��irL o SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E, HAZE I ON AVE., STOCKTON, CA li Telephone (209) 466-6781 MAY 18 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I-NVIMNMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hp9r"116SPIEWhMipplication 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 � o Cit �Z) t Size PM Owner's Name r_t..� Address �d-.ti►r[ a Phone i Contractor 40&4 Address �� I �e 7_Gbdv—Q License No Ca Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ['I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth l I Eastern ace Seal Installed by Repair Work Done [ ,�-Type of Pump 5F ' j=`-.H,P: _" State Work Dane a .- Well Destruction ❑ Well Diameter Y { Seali g Materia! itop_SO'1 N Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I ] DESTRUCTION 11 INo septic system permitted if public sewer is N S available within 200 feet.) Q ! F, Installation will serve: Residence_ Commercial_ Other I /',Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/MfgCapacity _ No. Compartments / --.,..PKG. TREATMENT PLT. ❑ Z_ Method of Disposal Distance to nearest: Well t "Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to pearest: Well ` Foundation Property Line SEEPAGE PITS I I Depth Size }' r Number j SUMPS f_1 Distance to nearest: Well �' '' Foundation Property Line =DISPOSAL PONDS ❑ ' I hereby certify that t 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. t 'Home owner or licensed agent's signature certifies the following: "I certify that in the performance of-the-workfor 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." .J r The'ap must call for squireaspect" ns. Complete drawing verse side. :- d Signk d Title: _ -date: r R DEPARTMENT USE ONLY << a Application Accepted by Date Area a!r Pit or Grout Inspection by Date Final Inspection by./ - mss!S -!.__ 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 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. `nom +.EH1144-28 .-24{REV.1/n5) EH � ©—J�r + y