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APPLICATION FOR PERMIT " ECEIVED11 SAN JOAQUIN LOCAL HEALTH DISTRICT AU 2 0 1990 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is heteby 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. Job Address 00,:?o R1 RJ City Lot Size PM Address Md�f� StPhone II Ic�t�E� �� { �� Owner's Name � ._... Contractorkt IXoL A&p2 Address License No.t p.,q2%a I Phone_ TYPE OF WELL/PUMP: : ' NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION D 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 ❑ I dustrial El Open Bottom D.M6nteca Dia. of Well Excavation Dia. of Well Casing omesticlPrivate D Gravel Pack D Tracy Type of Casing Specifications f'I Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by A _ Repair Work Done ❑ Type of Pump S' H.P. State Work Done Well Destruction 1:1Well Diameter *� Sealing Material (top 50') Depth Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I 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 D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. I-] , Method of Disposal r 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 i I Depth Size Number SUMPS Cl 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 laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "f 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 follo ng: '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 Cali rni The applic call for ail reclu& inspectio Com to drawing on v a side. /� Signed X Title: Q/1/1- Date: `j R DEPARTM NT USE ONLY �yJ Application Accepted by Date �' Arad 2- Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK it CASH RECENED BY DATE PERMIT'N4. + EH 13-24 IREV.i/H 51 } el EH 14-28 � t �^ O