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i APPLICATION FOR PERMIT I ' �: _ •-�;� SAN JOAQUIN LOCAL HEALTH DISTRICT -4YME1� , 1601 E. HAZE T ON AVE., STOCKTON, CA R E CEI VED _ - Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL .a 1990 f (Complete in Triplicate) ENVIRONMENT !N$ . {�� T Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worRrtteggin,�d��d.'T�-8�plication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.1862 for well/pump and the Rules artd Regulati A154the San Joaquin Local Health Distric""t7 �7 r C j r ' Job Address 6 oG J 7 7G iSrLL L J d -.—. City l Lot Size CvexpM Owner's Name _S~ -e_,)L ! 4 Address 6 �l�l�.i�OEa Phone / a P r 1 . �� Contractor �(� t-th+' Address - Q License Nr� .� � Phon .22 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION n' -PUMP INSTALLATION SYSTEM SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A92 SEWER LINES ZCA? ;! 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 �omestic/Private dw-avel Pack ❑ Tracy Type of Casing IDY ,,!�y�`` Specifications i I`I Public hl Other ❑ Delta Depth of Grout Seal / p Type of Grout�.+- r✓'� I I Irrigation _Z00-Approx. Depth I i Eastern Surface Seal Installed by - r Repair Work Done ❑ Type of Pump H,P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I 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: I Water table depth SEPTIC TANK - ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 0 . LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I I Depth # Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4 I-hereby'certify-1h.at t have prepared-this-application-i d-that-lhe-work'wi11-be done iri-accoTdanee"witK-Sbn Joaquin county or=dinances siate'-laws;ari7t 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, 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 sRt call for all required inspections. Complete drawing on reverse side. r Signed X Ci Title: Q Date: FOR EPARTMENT USE ONLY h a Applicati ccepted by Date ~h�((7� B Area Pit or ou Inspection bb Date nal Inspection by Date'3 j `J Additional Comments: 10 10"/Gl- �1 J� AU G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ lVanteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20(X9, Stk., CA 95201 . � ti FEE INFO AMOUNT DUE AMOUNT REMITRECEIVED BY TED DATE PERMIT'NO. t� CASH +.EH 13-26(REV.11n51 f G 3 v 'L7/q� k/_ EH 1�-26 � ��