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i APPLICATION FOR PERMIT E D SAN JOAQUIN LOCAL HEALTH DISTRICT y 1601 E�HAZE:.T;ON AVE., STOCKTON, CA L "' Telephone` (209) 466-6781 DEC 6 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUFP„IRRONMEN- AL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 9 Ji)aquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. r Job Address �+ Lot Size PM . Phone r�+l I Owner's ame Address i q Contractor Address License No. Z3 Phone G TYPE OF W -C-L/PUMP: 4! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION A--' SYSTEM REPAIR 5�� OTHER ❑ C. 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' P�Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications k ('1 Public I] Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _/ I ' -Approx. Depth` ,t I astern Surface Seal Installed by Repair Work Done fd Type of Pump H.P. State Work Done 'f Well Destruction ❑ Well Diameter Sealing Material (top 501 a Depth Filler Material IBelow 501 -- `TYPE OF-SEPTIC WORK: I.EW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is f `1 available within 200 feet.) I Installation will serve: Reslidence_ Commercial_.— Other ' ' y Number of living units: I Number of bedrooms p 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 r Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER' ED ❑ Distance to nearest: <Well Foundation Property Line '' SEEPAGE PITS I I Depth Size Number 3 SUMPS ' istance to nearest:lf-We11'`” i Foundation .Property Line DISPOSAL'PONDS ❑� - —• ---_..._.....�w�.._.� _. � t 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 licens ant'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 pers n such nner as to beco a subject t orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo wing: "I certi at in the rmance t e work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifornia." a The appli nt f all re re t let drawing on r de. or , ip � fZZ _ Signed X Title: `"r Date: FOR DEPARTMENT USE ONLY 77 x, � ^ '`Date•"' "o"�J Area 1 .Application Accepted by l Pit or Grout Inspection by I� Date Final Inspection bye .-_ ..Date IL-`�' � Additional Comments: I` ❑ Stk `-466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 _4 Applicant - Return all copies`to: Environmental Health Permit/Services 1601 E. Hazelton•Ava.;•P.O.`Box•2W%9 5tIk., CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, INFO rc CASH ♦.EH 13.241R&V "Kel EH 14-2a I�'