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APPLICATION FOR PERMIT Vp U SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA NOV 10 1989 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERM IT/SERVICL;S 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 City Lot Size PM Job Address ,u �- � 1i� Phone Owner's Name 1 ddress S (" ' ! Phone Contractor aOr�i Address License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM'REPAIR C] 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 C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Specifications Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Type of Grout ,e[;l,Pubiic ❑ Other � [7 Delta _ � depth of Grout Seal � YP Grout_._:_._, ! irrigation --Approx. Depth l I Eastern Surf ce Seal Installed by H.P. State Work Done 1�L Type of Pump Repair Work Done �� Y Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 _ }� TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public.stiwer is ^ available within 200 feet.l Installation will serve: Residence '`Commercial; Othei Numb_er,of living units: Number of bedrooms p/ RAITepth Character of soil to a depth of 3 feet: } SEPTIC TANK ❑ Type/Mfg Capacity REE nts Method o Disposal ' n PKG. TREATMENT PLT. ❑ Nnv t y(lig, �d�p 191 Distance to nearest: Well Foundation 8rJ,7t1Z r SAN 10,41"NGE)UNTY LEACHING LINE ❑ No. & Length of lines TcEU@hAl&NEAI TH SFRV iCES FILTER BED ❑ Distance to nearest: Well Foundation ENVIRONWA��ILHZALTH DIVISi N SEEPAGE PITS i 1 Depth Size Number [. SUMPS L] Distance to nearest: Well Foundation r Property Line ` DISPOSAL PONDS ❑ hat the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and t 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,1 shall employ persons subject to workman's campensa tion laws of California." The applicant call for �11re red�incbons. Complete drawing on reverse side. I Signed X Title:_— p/ - Date: DEPARTMENT 69 USE ONLY / Application Accepted by f date Area Pit or Grout Inspection by Date Final Inspection by pate/� ' � k Additional Comments: T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO EH 13-24 "JS o EH 14-26