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4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT r1 1601 E. HAZEL T ON AVE., STOCKTON, CA RENIV kx +�1 Telephone (209) 466-6781 . NOV 10 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH P�I�MIT/SERVli,ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin Local Health District. yy� Job Address �G% h G-c�`_ City '/! Lot Size PM ( Owner's NameC�M� f'�70�--� Address t=!V 10 �. LLI:r ��... Phone ^?, if Contractor v-<<% Address/=-!V A6!4e401A �!§ - License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR A- OTHER A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 jN-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Jt Type of Pump-- H.P. Y1.4P State Work Done %LSP Well Destruction ❑ Well Diameter Sealing Material (top 50') f Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) N Installation will serve: Residence_ Commercial_ Other l Number of living units: Number of bedrooms PAYMENT oral Character of soil to a depth of 3 feet: Water� 0O SEPTIC TANK ❑ Type/Mfg CapacityNo. Cornnpar PKG. TREATMENT PLT. F-1Methoq prW491 Distance to nearest: Well Foundation - Property a LEACHING LINE ❑ No. & Length of lines Total lengt iJ Nh FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ 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. 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 applicanntustt call for all required inspections. Complete drawing on reverse side. Signed X�IC�-'�>_ �,�[��.-� Title:� Date: ---�� FR EPARTMENT USE ONLY l Application Accepted byAkeDate _07Area 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 INFO FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"NO. + EH 13-24(REV.t/t35) EH 1428