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APPLICATION FOR PERMIT NT SAN JOAQUIN LOCAL HEALTH DISTRICT EE RECEIVCEIED 1601 E. HAZEL T ON AVE., STOCKTON, CA I' Telephone (209) 46676781 SEP l g 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL. HEAUTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hVMJ4 LFRWL0fi6application 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. § 4+` 'S J t t, Lu" ! vC=« City 0� Lot Size PM Job Address Owner's Name C�r ` Address ? uG Phone f 4 �(�r ��ty��/� License No Phone Contractor + '' ` "� �� Address 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 v AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEAL, PROBLEM AREA :CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -0,Manteca. =Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy -� Type of Casing Specifications I M Public n Other I L] Delta Depth of.Grout Seal Type of Grout I I Irrigation --Approx. Depth 1 Eastern rface Seal Installed by 9 r Repair Work Done { Type of Pump H.P. State Work Done Well.Destruction ❑ !.Well Diameter Sealing Material Itop 50'1 4' S Depth T" Filler Material (Below 501 (1 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is xJl available within 200 feet.) -� Installation will serve: Residence_� Commercial_ Other _ - _ Number of living units: Number of bedrooms �. a Character of soil to a depth of 3 feet:] "" Water table depth SEPTIC TANK v - F ❑ Type/Mfg Capacity" --No.-Compartments-- - •-- PKG. TREATMENT PLT. ❑' Si" Method of Disposal t ti •..__, Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ea Distance to nearest: ' Well Foundation Property Line --� f SEEPAGE PITS I i Depth Size Number Cl...Distance to nearest: Well Foundation - Property-Une1—,— DISPOSAL PONDS :❑ ' r 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." 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, I shall employ persons subject to workman's compensa tion laws of California." The applicant st call for all req -e 'ins ctions. Complete drawing on reverse side. Signed X - f -C<_ --. . Title � �iC Date: � 7 R DEPARTMENT USE ONLY Application Accepted Pj tion Acce d b ! date Area y Pit or Grout Inspection by Date Final Inspection by Date% i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE RMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO j + EH13-24(REV,1/K 5) 35; 3$ f.�,'��- 9—7-o—JP1 �O ;33 EH 14-26 k