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APPLICATION FOR'PERMIT 77- <br /> SAN <br /> 7SAN JOAQUIN LOCAL HEALTH'D ` <br /> (STRICT PAYMENT" <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVE® <br /> Telephone (209) 466-67'81 <br /> - APR - 9 1989 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUE. <br /> N JOAQUlN COUNTY <br /> (Complete in Triplicate) PUBLIC HEALTH SERVICES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or iJtal1yt}ie�nNherecn Ac Tbhed,(TM5s4application is <br /> made in with San Joaquin.CounryEOrdinance.-Na 549,for sewage or No. 1862 for well and the Rules and Re Regulations of the San Joaquin <br /> Local Health Distract a�" ,** ass- "+ uj.'* >.,.. 9 <br /> �� �yy� <br /> Job Addresstnt�Y of .Lia. yr - moi'" tY - Lot Size PM <br /> Owner's Name Vad {i/CJI?a # s an6 Address ne Z�:/ <br /> Contractor cC� Address //CLGGLense fro. � l Phone I <br /> TYPE OF WELL/PUMP: . .. NEW WELL'f WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> „DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> -C f �" II IT SUMPS "'" """' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �f <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing .� <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing <br /> - Specifications <br /> f'3 Public <br /> Other ❑ Delta Depth of Grout Seal AJ i <br /> f Type of_ rout <br /> Irrigation r _..Approx. Depth I I Eastern Surface Seal Installed by ,� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction, Cl Well Diameter Sealing Material (top 50') " <br /> Depth Filler Material leelow 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION (-I- REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a.depth of 3 feet: <br /> SEPTIC TANK El Water table depth <br /> PKG. TREATMENT PLT. ❑ TypelMfg Ca acit <br /> P Y No. Compartments <br /> °� <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE. ❑ No. & Length of lines Total length/size <br /> FILTER BED C3Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size _ Number <br /> _,4-SUMPS �_ �_ 0. Distance to nearest:.,,= Well Foundation =_ Y .Property Line.=� <br /> DISPOSAL PONDS �O <br /> 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 <br /> rules and regulations of the San Joaquin Ldcal Health Dr%trict. <br /> 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 r <br /> employ any,person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i <br /> certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The applicant ust call for all requir d inspections. omplete drawing n re rsa s'ife. <br /> Signed X Title: (i/LC 6 <br /> } Date: <br /> r� FOR DEP R re 'se <br /> USE ONLY <br /> Application Accepted by �O <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by_ <br /> r _ Data <br /> Additional Comments: :r 4 v <br /> ❑ Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200$, Stk., CA 95203 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE ZEREIN .+.EH344(REV.iEH to-2a S <br />