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� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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. y� Job Address DC) +`. .. r�iJ City 10.0, Lot Size PM Owner's Name r. D SAJ V!J-c- .,_ Address 1-7-9 WQO0&I fJ_IL Phone2 Gr- 'I-� L-N Contractor G2o .5 Addresse? License N2 /7 gS _Phone y-4f��5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-R DESTRUCTION PUMP INSTALLATION`,F SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK'7-0 SEWER LINES DISPOSAL FLD. 100 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 ❑ Domestic/Private `RrGravel Pack ❑ Tracy Type of Casing /0 VC Specifications ❑ ;Public ❑ Other ❑ Delta Depth of Grout Seal 210 _ Type of Grout ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by-ON rRAC.TAC Repair Work Done ❑ type of Pump H.P. 1 State Work Done 67CAJ -J' Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 - 1, TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION E DESTRUCTION El (No septic system permitted if public sewer is Y- available within 200 feet.l Installation will serve: Residence— Commercial— Other ; } Q Number of living units: , Number of bedrooms y a n Character of soil to a depth of 3 feet: Water table depth _ V SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �V FILTER BED ❑ Distance to nearest: Well Foundation Property Line - ^1 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 o 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-1 tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: -ONLY q Application Accepted by Date 1 Area Pit or rout spection by 14A, r Date 3-6-90 Final Inspection by I Date h Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 o set L.0 f blas Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 INF MOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT ND. `r + EH 13-24 1REV.1/H5) �Q�r.' f Q� ./ T� 4y, J EH 14-26 7 r v ti