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APPLICATION FOR PERMIT E V E D SAN JOAQUIN LOCAL HEALTH DISTRICT NOV 2 7 1989 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRONMENTAL HEALTH Telephone (209) 466-6781 PERMIT/5cRVI%tS PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) 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. f( Job Address /807 V"hiS 4161! City S{-o4,k6h Lot Size I zfx PM Owner's Name S\vh [NtSt Address ZZ- 1=%t w�� 4a�4, � Phone �77�- 6°(eL — Contractor Cc ¢ f4r cz ,L Address `ZC2.7i 0244 r X0'1 �+� License No.ENI t4 v Phone 7L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES Tlt DISPOSAL FLO. PROP. LINE !c1 FOUNDATION 25� 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 ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications I'1 Public ❑ Other Ll Delta Depth of Grout Sealt `11h vF 13J/I.c1 Type of Grout___ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by eMti Ty ONR c5r r>N7�fr97+7 fwuL} Repair Work Done ❑ Type of Pump H.P. State Work Done''ti Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below SO') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is 0 available within 200 fast.) 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 Ll 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 Dibuict. 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." Contractors 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 for all required inspections. Complete drawing on reverse side. Signed X�A� V� Title: LG.vt s cd 4tm / AsL�A.-�Cw�.`'� Date:47 TMENT USE ONLY Application Accepted by / Date �" Area Pit or Grout Inspection by 14i[�w.� ^ Date /_'/3 Final Inspection by °"d Date Additional Comments: ❑ Silk 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 AMOUNT DUE IUNT REMITTED CX H RECEIVED BY DATE PERMIT NO. INFO i ♦ EH 14.21(REV.rrae) �' O Ilag O EN 14.211