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IPP APPLICATION FOR PERMIT PAYMENT ��7 SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., ST IOCKTON, CA Telephone (209) 466-6781 MAY 2 9 1989 PERMIT EXPIRES TYEAR FROM DATE ISSU EVIAN JOAQUIN COUNTY (Complete in Triplicate) Lid HEA4TH SERVICES 06 /3j� om p p ENVIRONMENTAL HEALTH DIVISION Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size 40.40 PM ne Pho Owner's Name Address Contractor ddress L` se No. Phone TYPE OF WELL/PUMP: NEW WELL 1Y WELL REPLACEMENT DESTRUCTION ❑ Spe— n1t�fPU P INSTALLATION ❑ SYSTEM REPAIR El OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Excavations. 6,11 ❑ Domestic/Privatg� ❑ Gravel Pack ❑ Tracy Type of Casing) Specifications M PublicCl Other P Delta Depth of Grout)Seal Type of Grout j. I E Irrigation IN-Approx. Depth I I Eastern Surface Seal installed by Repair Work one ❑ Type of Pump H.P. State Work Done Q Well Destruction ❑ Well Diameter Seating Material Itop 50'1 N Depth Filler Material (Below 50'11 j TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is (n j available within 200 feet.I Installation will serve: Residence— Commercial_ Other Number of living units: IM Number of bedrooms Character of soil to a depth,of 3 feet: Water table depth SEPTIC TANK ❑ _ hype/Mfg Capacitly No. Compartments PKG. TREATMENT PLT. ❑ I� Method of Disposal Distance to nearest: Well Foundation Property line IN LEACHING LINE ❑ No. & Length of lines Total length/size .i � FILTER BED ❑ Distance to nearest: Well Foundation Property Line I iM SEEPAGE PITS i I Depth Size Number ;I SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I� 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 agents 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." Contractors hiring or sub-contracting signature i 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 m t call for allrequired i sp ionsomplate drawing on reverse side, I Signed X Title: Date: J I FOR DEPARTMENT USE O LY Application Accepted by Date Area 24 ' Pit or Grout Inspection by Date Final Inspection,b – Date r -, Additional Comments: r ❑ Stk 466-6781 Ll Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-638 Applicant- Return all copies t��: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 ,r IFEE NFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. +.EH 1321(REV.I/A5) �I. J�/ / q�— 1 EH N-26 II _ t