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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE�_TON 'AV ., STOCKTON, CA RECEIVE .� 'Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 6 1989 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install this application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the n i4i�tfdr mhe San Joaquin Local Health District. Job Address City �' Lot Size PM FGS ✓ C i It', 9 44 0 C7 Owner's Name Address r4l 7 Phone r �^! Contractor .J Address t,492r License NOAZ 3143 Phone 6-TfO TYPE OF X4466PUMP: NEW WELL ❑ WELL REPLACEMENT �© DESTRUCTION LJ PUMP INSTALLATION ❑ SYSTEM REPAIR rte' 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . ES-Eromestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications • �I.1 Public F Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair-Work Done Lam'/Type of Pump su H.P. State Work Done_ Well-Destruction ❑: Well Diameter Sealing Material (top,&') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 RFPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) i •' .i t Installation.will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms = I Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y PKG. TREATMENT PLT. ❑ Method of Disposal ? Distance to nearest: Well Foundation Property Line .r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED .� . - Cl Distance to nearest: Well Foundation Property Line z, e SEEPAGE PITS 1 1 Depth Size Number SUMPS r Y yL-I Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS ❑` s 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 regulatio an Joaquin Local Health District. Home owner rcensed agen signature certifies the following: "I certify in the rmance of the work for which this permit is issued, I shall not employ any arson in such mariner as to becom subject w rkman's mpensation laws California." Contractor's hiring or sub-contracting signature certifies t e following: i cert( at int ape c ft work for hich this mit s is ad, I shall a Ioy persons subject to workman's compensa- tion la of Californi The a licant o 1 req d ' rawi g on r er ✓ Z Signed r Title: ate: FOR DEPARTMENT USE ONLY 2 Application Accepted by Date r /5- AreaOr ;0 Pit or Grout Inspection by Date Final Inspection Data ZL - 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 Ii FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-241REV.I/H5) '�_A_1t EH 14-28 I