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I� APPLICATION FOR PERMIT �'�s�' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CACPR t: Telephone (209) 466-6781 . D NOV f Q 1989.i PERMIT EXPIRES TYEAR FROM DATE ISSUED I (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 heRps II'' ion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No, 1862 for well/pump and the Rules and egula io aquin Local Health District. I' Job Address ,A d City Lot Size PM 0 Owner's Name.Utrc Yn Address / r Phone?,?/"' to 61 V ContractorAddress License No./ �"� 7� Phone TYPE OF WELL/PUMP:. �$, ,;NEW WELL ❑, WELL REPLACEMENT El DESTRUCTION ❑ PUMP INSTALLATION-E] SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK ;SEWER LINES DISPOSAL FLD.' PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - f'1 Public r ❑ Other F1 Delta' Depth of Grout Seal Type of Grout 1 I-r!irigation j i d _.App'rox. De I Eastern Surface Seal Installed by p _ Repair Work-Done--L]: =Type-ofPumpf- =t'�^�� H.P:-;•�-f!•-5�---�---�-�- �--rt-�- —State Work Done _ Weil Destruction ❑ Well Diameter ! Sealing Material (top 501 Depth Il Fillet Material f BeloW 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I. REPAIR/ADDITION ('1 •DESTRUCTION 111No septic system permitted if public sewer is. I� a. available within 200 feet./ Installation will serve: _Residences Commercial i—Other. Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: ? Water table depth SEPTIC TANK ❑ Type/Mfg '_Capacity - No. Compartments PKG. TREATMENT PLT. ❑ �4 - ' 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 NFoundation Property Line Y`= SEEPAGE PITS I I Depth Size — Number SUMPS ❑ 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 District. C� 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 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: -4 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 ust c;forrequiredinspections. Complete drawing on reverse side. Signed X Title: Date: C1` FOR DEPARTMENT USE ONLY Application Accepted byDate v ` Area Pit or Grout Inspection by Date Final inspection by Date U Additional Comments: ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 CK CASH RECEIVED BY DATE PERMIT*NO. + EH 1 3-24 IREV.1/A 5) EH 14-29 1I 6 5 99-�'�7Z-'^ 4 If �':