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4. - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT- L, L 1601 E. HAZEL T ON AVE., STOCKTON, CA ' Telephone (209) 466-6781 PERMIT EXPIRES-1-YEAR FROM DATE ISSUED MAR 27 1989 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worloherernescribed. 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 Districtt..�& i Job Address ^�� /yPr,(� City 7 `CJ Lot Size PM /' �� Owner's Name E��Q t_ _ Address ��r t �'L ! ___ Phone ZZ Contractor /9 Address //IJ/Llffe09License No.1/419 1 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ r 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 } 15;,7Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public ❑ Other 1 1-1 Delta Depth of Grout Seal Typpee of Grout I I irrigation ,•4 - _Apprax: Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done ' Well Destruction~ C] Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 TY PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I Wo septic system permitted if public sewer is f '` available within 200 feet.) f Installation will serve: Residence _ Commercial_ Other 0 k,Nu`mber of diving units: Number of bedrooms a t Character-of soil to a depth of 3'feet� Water table depth tw l r '_:n SEPTIC TANK ❑ %Type/Mfg Capacity No. Compartments MG.' TREATMENT PLT. ❑'.J\,, I Method of Disposal iDistance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ILTERIBED' E] Distance'to nearest Well Foundation Property Line r _ SEEPAGE PITS" 11 Depth i - Size Number SUMPS i ❑ Distance 3o nearest: Well Foundation Property Line DISPOSAL PONDS 0,- "=_1 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"J&aquin:L•ocal-Health bisthct. III 111111 Home owner or licensed agent's signature'certifies tWfollowing: "('certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subjeict-to-workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followings"1 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 applicantr requ" tions. Complete drawing on revs side. A Z Signed X Date: 4 •,} " lo, as. -FOR EP RTEi11ENT USEO Y Application Accepted by ' - _Date- ! Area 1 Pit or Grout Inspection by Date Final Inspection by / Date 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24(REV,t i ra sl �[ n EH 14-26 /�+_l