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j APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA JUN 2 2 1990 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. Job Address �,f "0v%�� City Lot Size PM z Owner's Name ��"'7.1 �' _ Address _ �t� Phone Contractor .C�>�IL__ &R-9`_30 tense No. �3 Z Phone . —�+ � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION 1).( 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 *nmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [-I Public n Other n Delta Depth of Grout Seal Type of Grout---- I rout _I I Irrigation —.Approx. Depth l I Eastern f Surface Seal Installed by _ ` Repair Work Done /_ Type of Pump H.P. � - State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'I Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR)ADDITION I I DESTRUCTION I 1 INo septic system permitted it 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 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 I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ aws, and 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 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state l rules and regulations of the San Joaquin Local Health DRtrict. 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 must call f r all required inspections. Complete drawing on reverse side. y/ (� Signed X Title: ��! GQ Date: 4 e ��lGj —Z 0 OR DEPARTMENT USE ONLY Application Accepted by Date � a v Area 1� Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments: ❑ Sik 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 CK RECEIVED BY DATE PERMIT'NO. ♦ EH 13-24 1REV.t/H 5) to EH 14-26 Z{p �, O