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P 3o APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT OCT 16 1989 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N PERMIT EN�HE�RMITISERVICI~S. (Complete in Triplicate) Application is hereby made to the San Joaquin Locale Health District for a permit 10 construct and/or install the work herein described. This application is made in-compliance with San,Joaqurn;Co.unty,Ordinance No:549-for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District L � Job Address ,r `' City ��u Lot Size PM Owner's Name L(f•�. �. a+ Address I%4. ,V41z /.3`f� 7m�-� Phone N Contractor S Address 5-� Q / License No. 9901113 Phone TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK /SD z SEWER LINES DISPOSAL FLD._15--0— 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 bQX Dia. of Well Casing ❑ Domestic/Private K Gravel Pack L Tracy Type of Casing Specifications �NGE�tolu�7- V Public n Other {1 Delta Depth of Grout Seal 40& Type of Grdl t ?p nLad I-_. I i Irrigation —Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State VTnrk Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments T PKG. TREATMENT.PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1-1 Depth Size Number SUMPS Ll 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 jaws,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 m st ca qu ll for all rei. d inspections. Complet drawing o e " i e. ► / qty Signed X tle: + Date: FO PA ENT USE ONLY Application Accepted by Date �r Area / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:al� a 1 1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 84 41 ❑ 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 REMITTEDRECEIVED BY DATE PERMIVNO. r INFO . -CAS FI +.EH 13-241REV.1ia5) 7D.U() 7p-01) .aK ,� /O-Z-" 1Sr1-Z035 EH 14-26 "`��7/1