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5� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTQ CHEW 1601 E. HAZE I ON AVE., STOCKTQN, CA Telephone 12091 466-6781 SEP 2 7 1988 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL NEALTH y PERMIT/.''GG pp�j�^� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrA9 TF 9pplication 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. ct Job Address SI 144— / S' City S�M Lot Size PM Owner's Name 141— l'e41M Address Phone Contractor'14 Address Q JI-229 ��-Cd/��cense No.��Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS❑ DESTRUCTION ❑ PUMP INSTALLATION,R fZE-i JAe fU>3YSTEM REPAIR'❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. I 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 ,yDomestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other Ll Delta Depth of Grout Seal Type of Grout 1 1 Irrigation --Approx. Depth I I Eastern /� Surface Seal Installed by _ Repair Work Done ❑ Type of Pump " H.P, � `�t f State Work Done_iiftl- �y 1 t , Well Destruction ❑ Well Diameter Sealing Material(top 50') _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is y available within 200 feet.) Installation will serve:1 ResidenceCommercial_ Other A IL -rNumher.of living units: Num ef�fabedrooms „a, i Character o 'soil to a depth of 3 feet i Water table depth LA SEPTIC TANK ❑A Type/Mfg_ Capacity No. Compartments ) PKG.'TREATMENT PLT.'❑ Method of Disposal _ 1. Dis an�e`it�trearesi:" `V17ell'" (� Foundation Property.Line LEACHINGLINE ❑ No. & Length of lines ~� Total length size FILTER BED Q Distance to nearest Well Foundation `Woperty Line 1 SEEPAGE PITS C I Depth Size i Numbe f SUMPS Ll Distance to nearest: Well Foundation i 'Property Line a DISPOSAL PONDS ❑ � i I hereby certify that I have prepared this application and that the work will be done in accordance with San Jbaquin county ordinances, state laws, and '€ rules and regulations of the San Joaquin Local Health District. f Y Home owner or licensed agent's signature certifies the following: "I certify that in the performance of�tha 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." 1 j The applican f allre ctions. Complete drawing on rev rse side. e 1 Signed X Title: �` ._ � Date: +� FOR 4EPARTMENT USE ONLY Application Accepted by Date Area k Pit or Grout Inspection by Data Final Inspection by }n Dateld-/�1 _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY DATE PERMIT-NO. y +.EH 1324(REV.i/n 5) EH 11-25