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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 OCT 1 G 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herRegulations o the anr plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an!MMMJoaquin Local Health District. Cl772 Job Address 11s CSI City ` tvI Lot Size PM Owner's Name Address -7�7`'- s -� 'L � Phone c a Contractor � ' Address �/ � � ��s License No. a14Phone 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications 4"1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout _ — I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump �'�'— H.P. -9 te Work oneWell Destruction ❑ Well Diameter Sealing Material (top 50') f�Depth Filler Material (Below 50'1*.&1 -- `o TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION I I (No teptic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C/) PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (� SEEPAGE PITS I I Depth Size — Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Di§trict. 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'Jh tion laws of California." Contractor's hiring or sub contracting signature certifies the folio ing: "I certify that in the performance of the work forpermit is issued, I shall employ persons subject to workman's compensa- tion laws of lifor The applica t must all for al qu e i ions. Complete drawinside. Signed XTitle: Date: /�+ FOR DEPARTMENT USE ONLY _ Applicata Ac pt /�ed by / Date /" / Area -2/ Pit or Grout Inspection by Date Final Inspection by 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH p �j p +.EH13.24(REV.1/x5) LS vel /0—AO_9yg 6�— EH 14-2e ✓✓✓