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APPLICATION FOR PERMIT Pft SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVEL) 1601 E. HAZE L T ON AW b �� a f.,,STOCKTOIV, CA DEC 6 1989 Telephone (209) 466-6781 e� PERMIT EXPIRES 1-YEAR FROM DATE ISSUENVIRJNMENTAL HEALTH (Complete in Triplicate) PERM V USE.RVICES 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. 1 Job Address 476 0 C— r 1! AIL City Lot Size PM 4L /1" Owner's Name Address Phone REPLACEMENT 0 DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy n �nnr• iVLYY-WILL, LJ y WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE'TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU." 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 C71 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public I=1 Other ❑ Delta Depthlof Grout Seal Type of Grout I I Irrigation -Approx. Degr- ), astern SurfSeal Installed by ti Repair Work Done Type of Pump v H.P. State Work bone Well Destruction ❑ Well Diameter Sealing MaterialJtop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 )RERAIR/ADDITION f] DESTRUCTIONI 1 INo septic system permitted if public sewer is r ] I r available within 200 feet.l Installation will serve: Residence + ;Qommercial jJ Other *i r Number of living units: Number of bedrooms 1C1 Character of soil to a depth of 3 feet: 0 r _ Water table depth SEPTIC TANK ❑ Type/Mfg,!, . I s Capacity It ti No. Compartments PKG- TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation .._, Property Line LEACHING LINE ❑ No- & Length of lines i Total length/size >I FILTER BED © Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size 1 Number SUMPS Ll Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have re ared this application and that the work will tie done in accordance with San Joaquin county ordinances, state laws, and" rules and regulations a San aquin Local Health Di'ktrict. i Home owner or li nst agent's sig lure certifies the foil in : "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such manner a to become su ' t o an's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f lowin : "I certify that- he pe the ark for th a it is issued, I shall employ persons subject to workman's compensa tion laws o California. ' The applic nt m It for a ired in late dr ing on a ers i Signed X Title: � Date: FOR DEPARTMENT USE ONLY Application Accepted by Z �/ Date Area Pit or Grout Inspection by Date Final Inspection by Date \4 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASE+ 13-241REV.r/85) EH 14-28 ��