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x' 4' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTVt 1601 E. HAZELTON AVE.,-STOCKTON, CA t Telephone (209) 466-6781 f PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED17 X989 (Complete in Triplicate) a ,„ T }�tALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workF:4� ff$4 A lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and gulations of the San Joaquin l f" Local Health District. !!�� r��p Pa,fC!/F� !- ('i s,I,.,' x w t t .. C cf5— Zoe 0 -IV ` Job Address dT�1v�r^ ' jc)G+Ci� ` KI x f3i. .' .f,�> City Lot Size PM i Owner's Name6/.f�r�../JC�oY,Nitl�� fq dress J Phone —,V4 7 Contractor Address F. ' License No. Phonefm ! TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ - Y t PUMP INSTALLATION,❑ �_ ,SYSTEM REPAIR ❑_ OTHERs�OAr�pI"ra DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS fINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing T ❑ Domestic/Private ,ravel Pack El Tracy Type of Casing�yG' tJz RJEWl/Specifications ❑ Public � !/❑ Other ❑-Delta -x' Depth of Grout Seal 14a c7e '5 Type of Grout —$4ek 11 Irrigation Il�pprox. Depth C1 Eastern Surface Seal Installed by velar Jaw Repair Work Done ❑ Type of Pump 5y6 H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 c XafiCA+tri+n Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 , r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments S PKG. TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line �Q LEACHING LINE ❑ No"& Length of lines Total length/size r FILTER BED ❑ Distance to nearest: -Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number ( SUMPS ❑ Di'stance to nearest:- Well Foundation T 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 District.. Home owner or licensed agent's signature certifies the following: "I certifythatin 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: "1 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 ust call for all required inspections. Complete drawing on reverse side. r Signed X ' Title: A Date: !/I Y a1 � OR DEPARTMENT USONLY Application Ac ted by Date ,J Area Pit or Grout Inspection by Date - 1 Final Inspection bDate.?, 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 t r FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO H + EH14-14 SREV.t i H 51 1� ( '}� �Al O EH 14-18 �l i