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APPLICATION FOR PERMIT RECENED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 2 1 1990 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 Health 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 13293E Atkinson Rd. City Lot Size PM Owner's Name HLIGO VALLE Address 13293 E. Atkinson Rd. Phone P.O. Box 113 Contractor Cbehring Pn Address 17754 N. FW. 88, LOCkefOrd License No. 309031 phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATIONXX 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 ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by _ XJ Repair Work Done ❑ Type of Pump SUb, H.P. 71/2H State Work Done Well Destruction ❑ Well Diameter Sealing Materiai ftr 501 Depth Filler Material (Beld)w 501 __ V TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I - DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of;bedroorns= 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 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 OfSPOSAL PONDS ❑ U .. 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 ag 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 suc nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: ' c tify 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 Califo The applicant m f r all quired inspections. Complete drawing on reverse side. Signed X Title: Bkpr. Date: 08/19/90 FOR DEPARTMENT USE ONLY /3 Pit Application Accepted by Date` / Area �/`-� ' f) Pit or Grout Inspection by Date Final Inspection by 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 INFO AMOUNT DUE AMOUNT REMITTED CACK iSHU—r RECEIVED BY DATE PERMIT NO. EH+ EH 14-2a(REV.t/x 5) Q �'17