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r I APPLICATION FOR PERMIT ` i SAN JOAQUIN LOCAL HEALTH DISTRICT { ! PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA t Telephon'a (209) 466-6781 � +�'��® ! PERMIT EXPIRES TYEAR FROM DATE ISSUED MAY 2 9 1989- ' (Complete in Triplicate) SAN JOAQUIN COUNTY Application is heiehy mads to the San Joaquin Local Health District for a permit to construct and/or install t PUBLIC� � � q oon is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t ar AMI.Joaquin Local Health District. I Job Address !'Z Z -^ �4Y 4�� V v v� �] r City &4-- Lot Size PM r �I �p�� Owner's Name one Address Ph —� ContAddress License No. Phone TYPE OF WELL/PUMP: I� NEW WELL � 2�WELL REPLACEMENT ❑ DESTRUCTION ❑ PUIMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ eze DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO . LP" INE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ i �❑ Industrial 0 Q)en Bottom ❑ Manteca Dia. of Well Excavation Di. of Well Casing ❑ Domestic/Priv4 �GraveE Pack ❑ Tracy Type of Casing Specifications f Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation(e -1.Approx. Depth I I Eastern w Surface Seal Installed by _ iRepair Work Done ❑ Type of Pump H,P. State Work Done _ Well Destruction ❑ Weil Diameter Sealing Material (top 50'i I Depth Filler Material (Below 50') s TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l 1 DESTRUCTION I I Wo septic system permitted if public sewer is !E available within 200 feet.) ��, Installation will serve: Residence� Commercial_ Other Number of living units: Jl° 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 ❑ �;6stance to nearest: Well Foundation Property Line (� �i I .SEEPAGE PITS l I !jkDepth Size Number SUMPS ❑ :h Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS ❑ Ip \\\ 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 ageni's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not iemploy 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 must call for all required inspe_cjions. Qomplete drawing on reverse side. r Signed X Title: x Date: JrOR DEPARTMENT USE NLY Application Accepted by I Date G�� J" Area Z/ ! Pito Grout nspection by, � �f Final Inspection by Date ,I! ` Additional Comments: A. t /1`•6 aA* s41 i .❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 Applicant - Return all copies tO: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 IIID FEE II INFO AMOUNT DUE AMOUNT REMITTED CASR 1C RECEIVED BY DATE PERMIT-NO. EH 13-24' + EH 14-26IREV,i/»5) Q A�-017/rl O qQ13-q5 l'.i