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APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT JUN 15 1990 1601 E. HAZE T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES 11 (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. t� ��/�� ; Job Address S / GSA/ of Size PM wok *Own;r's Namel&�&�� V- ` dress . Phone I ctat ' '�`�� 4-0%& ress -ylam' cense No' Phone l V r jv-1 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 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 ❑ Gravel Pack'' ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta's Depth of Grout Seal Type of Grout__---. I I Irrigation _._Approx�Dep ('I,Easterh Surface Seal Installed by Repair Work Done ❑ T of Pu p �H.P. State Work Done_ Well Destruction ❑ 1 1111 iam f Sealing Material (top 50Depth �� y Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 f REPAIR/ADDITION l I DESTRUCTION l I [No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: }L '� Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines In Total length/size [ l FILTER BED El Distance to �nearest:V WeilrFoundation Property Line a !0 SEEPAGE PITS I I Depth Si OL Number SUMPS ❑ Distance to nearest: Well. Foundation Property Line DISPOSAL PONDS ❑ I �� 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, a rules and regulations of the San Joaquin Local Health District. 'Honie-owner or licensed-agent's signature certifies the following:;1.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 10 i�vorkman'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 tfiis.pe�mit isiss edl'sF alhemploy-persons subject to workman's compensa- tion laws-of,.California-. The applican sl call or re iced inspections. Complete drawing on rev se side. Signef X Title- Date: 4 14 9D I i FOR DEPARTMENT USE ONLY o ! 4 Application Accepted by Date Area Pit or Grout Inspection by Dat Final Inspection by Date 2 h f .e Additional Comments: t ❑ 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 AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT-NO. a.EH 13-24(REV.1/H 5) EH 11-28 1 r .dam