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APPLICATION FOR PERMIT DECEIVE SAN JOAQUIN LOCAL HEALTH DISTRICT c 1601 E. HAZEL T ON AVE., STOCKTON, CA J U L 2 6 1990 4 U � Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to the San Joaquin Local.Heath 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. 1B62 for well!pump and the Rules and Regulations of the San Joaquin Local Health taistrict. City Lot Size PM -- Job Address Owner's Name r Address � Phone _� Icense No. Contractor ess Phone TYPE OF �1/ LL/PUMP: NEW WE WELL REPLACEMENT DESTRUCTION E ❑ M REPAIR ❑ OTHFR ' v PUMP INSTALLATION El/ SY5 SYSTEM� �l ✓' s� DISTANCE TO NEAREST: SEPTIC TANK _.— SEWER LINES � DISPOSAL FLI) PROP. LINE FOUNDATION AGRICULTURE WELL _.— OTHER WELL PITS/SUMPS �1 INTENDED USE — TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION / /� 0 en Bottom El Manteca Dia. of Well Excavatio Dia. of Well Casing zs l 1 Ind trial P Type of Casin Specifications omesticlPrivate Ci Gravel Pack I� Tracy 9 1 ? Other ❑ Delta Depth of Grout Seal Type of Grout _ Public Irntration __.Approx. Dept I I Eastern rface Seal Installed byiLA Repair Work Done 17 a of Pump H.P. State Work Done r l atenallto Well Destruction Well Diameter r Sealin 9MP 50') Depth Filler Material 1Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION r } a ailableo septic systethin m rented if public sewer is 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 Ca acit No. Compartments ` SEPTIC TANK LJ TypelMfg Capacity_ '-1) PKG. TREATMENT PLT. ❑ —. Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED P Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 1 Depth Size Number — SUMPS I 1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS i 1 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 become subject to workman's compensation laws of California." Contractors 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." The applicant m call for II to i ins tions. Complete drawing on re r e side. Signed X Title: Date: — �+ � FOR pEPARTMEN USE ONLY �j Application Accepted by �~ �� Date �'< Z Area Z { Pit or rou nspection by r Date � 6 Final Inspection by�� T�r�r Date Additional Comments: Cl Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 Tracy 5-6385 ( V I, j/'L Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 01 6) FEE AMOUNT DUE AMOUNT REMIWCKRECEIVED BY DATE L10`ER1Mn'NO. LINFOEH 13-24 IREV.5-H 51 , C? y� L7 EH 1426 10 T