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} i APPLICATION FOR PERMIT �. SAN JOAQUIN LOCAL HEALTH DISTRICT � II ,:• _ 1601 E:HAZE' ON AVE., STOCKTON, CA Ur ! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 01 1990 (Complete in Triplicate) nn'' i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thervl�tl �AETi{��13pplicaEiun is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul s NUTUMMUShe San Joaquin Local Health District. _ I Job Address Cit a PM Ae Owner's Name dress rte{ Phone 93 - 46 Contractor16 Ti,.' ess 1 ` ense N Phone TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r 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 ❑ Domestic/Private ❑ Gravel Pack' - ❑ Tracy Type of Casing_' Specifications - -- �— ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 I 1 Irrigation / kApprox. Dep ti—•I I Ef stern Surface Seal Installed by Repair Work Done RW Type of Pump s. ■�, H.P, State Work Don Well Destruction ❑ Well'piameter Sealing Material Stop 50') Depth Filler Material [Below 50') � r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 RFPAIR/ADDITION I ) DESTRUCTION I I INo septic system permitted if public sewer is J ! available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: i 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 CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I he ared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulatio f the Sa oaquin Local Health District. Home owner or I' ensed agent's ignature certifies following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pe on in such ma or as to teco u act to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the f lowing: "i c that i orm ce of the work for whic t rmit is issued, I shall employ persons subject to workman's compensa- tion laws o C 'for i ' 01/ The appli nt st call r all f ns. C mplete drawing o da. Signed X Title: Date: lR DEPARTMENT USE ONLY Application Accepted by Date Y f' Area Pit or Grout Inspection by Date Final Inspection by 7 Date Additional Comments: �- ❑ Stk 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 I EE 1 t INFO AMOUNT DUE AMOUNT REMITTED . CK A CASH RECEIVED BY 1 DATE PERMIT NO. +.EH 13-24(REV.I I 11 51 0- 83 . EH 14-26