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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED {209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HAR. 0 1 1990 (Complete in Triplicate) SAN JOAQUIN COUNTY P I H- r.f r,E ,,, Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of install t H&� � lion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t at aquin Local Health District. Job Address O 6/A�+ L p 6 4 V J Al E City f_ SCA 4 I/Lot Size PM �--- n �y Owner's Name - IQ+ �� A dress�V JJ� A L --._� Phone O 3 r 7 Contractor . SF . jd�/Address 3 /)7;91;V License NoO� / d/d Phone t�3R_?�7 _ 1. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION -. , SYSTEM REPAIR ❑ OTHER ❑ 4� J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—. ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '+ *.� , +,► r. w ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private. ❑ Gravel.Pack.- .___„ .11 Tracy -:�- .Type of Casing- ` NSpecifications. M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout .{ I-Irrigation ,. Approx. Depth I I Eastern Surface Seal Installed by �+ Repair-Work Done-�X Type of Pump S./h H.P. IS State Work Done I&IA- 4i /Srjr�. c�V Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted it public sewer is I 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 Y No. Compartments PKG. TREATMENT PLT. ❑ ' q:'• v� _Method thod of Disposal j Distance to nearest: Well ,Foundation- S f?roperty Line LEACHING LINE ❑ No. & Length of lines �� f Total lengths/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I ' I SEEP.AGE PITS- a { I Depth Size � _ Number t SUMPS 0 Distance to nearest: Well Foundation 'Property Line i DISPOSAL PONDS ❑ S - 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: "I certify that in the performance of the work for which this permit is issued,J shall not " employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contfacting 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 qAfor all required ipVoctioin omplete drawing on reverse side. 3j Signed X Title: Date: e=,2 FOR DEPARTMENT USE ONLY 1 Application Accepted by DatArea Pit or Grout Inspection by Date Final Inspection by, Date,L1 i Additional Comments:� - 11 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV,i i n s! 4,7 3`� q p 4-2(S EH 1 4 I