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APPLICATION FOR PERMIT �3 r SAN JOAQUIN LOCAL HEALTH DISTRICTr '^`p 1601 E. HAZELTON AVE., STOCKTON, CA '�'' �� Telephorte (200) 466-6781 NOV 17 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ' VIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Thi Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of Sen Joaquin Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descf the f th application is Pp made in compliance with San Joaquin County r Local Health District. City � Lot Size PM I Job Address r N Phone XP, Address Owner's Name ' !< C� �Phone 1 w License flo. mac: contractor Address DESTRUCTION ❑ NEW WELL ❑ WELL REPLACEMENT OTHER ❑ TYPE OF WELL/PUMP: SYSTEM REPAIR �� i PROP LINE ; FUMP-INST-AL-LATIOW❑ DISPOSAL FLD. I SEWER LINES _ — I PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK _—{ AGRICULTURE WELL iOTHER,WELLI - FOUNDATION A•,; _ CONSTRUCTION SPECIFICA7lONS r, INTENDED USE TYPE OF WELL PROBLEM AREs Dia. of Well Casing .0 open Bottom T3 Manteca ~�� Dia- of Well-Excavation ❑ industrial ' 4 Specifications r `❑ Tracy Type of Casing DomesticlPrivate Ll Gravel Pack Typo of Grout l Ll Other*- HCl Delta Depth of Grout Seal' f f N [-I Public Surface Seal installed by 444 --Approx. Depth l 1 Easternt State Work Done._ a I # I 1 Irrigation , ,!n Type of Pump �7C.f�3� 'H'P' - i Repair Work Done ❑, �;l Sealing Material (top 50') Well Destruction511 r r ❑ Well Diameter �[3-=-- I -- � Depth iFiller Material (Below 50') r ¢ available within 200 feet.) . T TYPE OF.SEPTIC WORK: NEW INSTALLATION l l REPAIR lADDITION I 1 DESTRUC7iON i ! (No septic system permitted it public sewer is 4Commercial— Other -- r � Installation-will serve: Residence� � 444 1Number of bedrooms Water table depth Number.of living units: Character of soil to a depth of 3 feet: Capacity—�- No. Compartments I SEPTIC TANK ❑ Type/Mfg Method of Disposal r PKG-. TREATMENT PLT. ❑ Foundation Property Line -. Distance to nearest: Well i I Total length/size I LEACHING LINE ❑ No. & Length of lines Property Line Foundation I FILTER BED ❑ Distance to nearest:��` I. i I Number Size I I Depth SEEPAGE PITS _�._..-..:- -Foundation Property Line�� SUMPS D Distance-to-neatest. Well ( DISPOSAL PONDS ❑ l ha�eby certify that I have prepared this application and that the work will be dare in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D3trict. in the g Home owner or licensed agent's signature certifiasub ectlto workman s coympensat on laws of Califorrnia.that " Contract 5r s'huing or sub contract ng signthis permit is issued, I atu�e employ any person in such manner as to become l to persons subject to workman's compensa- certifies the folio i : "I certify that in the performance of the work for which this permit is issued, I shall employ tionlaws of Cali r !a." The apPlic t-m t-call-tor••all equir inspectio C-omplete drawing o rev r,e side. ' ( y T" Title: Sigfned X` j .r.- s s y! . `+ s ' f FUR DEPARTM NT USE ONLY i •-� � Date Area / Application Accepted by Date 3 7 s Date —�� Final inspection by Pit or Grout Inspection by I, ti j} Additional Comments: ❑ Manteca 823-7164 ❑ Tracy 835-6385 ❑ Stk 466-6781 ❑ Lodi 369 3621 Sika, CA 95201 "46 r Applicant" Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, i I CK RECEIVED BY DATE PERMIT'NO. I- FEE AMOUNT DUE AMOUNT REMITTED CASH q� } INFO t r.EH 13-24(REV.5/'K 5] EH 1426 _ ....