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0 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 'Vel L(,��, ) p, 1, 1601 E. HAZELTON AVE., STOCKTON, CAi Telephone (209) 466-6781 �r9 MAY 1989 PERMIT EXPIRES 1"YEAR FROM DATE ISSUED (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. x. Job Address �a City Lot Size PM �" Address �� Phone Owner's Name I 171 M1� fisc}Addrese-Q _ - p- r Contractor � �`�`� icense No `�'��'-'�"� Phone�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPL-ACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ j 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 emestic/Private ❑ Gravel Pack -❑ Tracy Type of Casing- Specifications %❑��-Public -i=l-Other Cl 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-< -e-t-1r— H.P. � � _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 q Depth Filler Material (Below 501 ,r/} TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I )-.,,DESTRUCTION l I (No septic system permitted it public sewer is.' available within 200 feet.) Installation will serve: Residence— Commercial—-.Other '^ ' ' - ;�Numbe►<of living units: Number of bedrooms _;-.-h r�r of soil to a depth of 3 feet: Water table depth .,SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ _, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I` FILTER BED ❑ Distance to nearest: Well Foundation Property Line ro SEEPAGE PITS 11 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 j rules and regulations of the San Joaquin Local Health-DiWidt: - . I 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, 1 shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must it for all required inspections. Complete drawing on r verse side. Signe Title: ' Date:-51Z 7 R DEPARTMENT USE ONLY / Application Accepted by } Date 1✓ Area Pit or Grout Inspection by Date Final Inspection by t Date 5-26-Y7 Additional Comments: '- -- ❑ Stk 466-6781 ❑ Lodi 369-3621 D'Manteca 823-7104 �❑,T�acyf 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 CASH KA RECEIVED BY DATE PERM17'NO. ♦.EH 13.24(REV.I/n 5f EH 14-2e I I� t