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APPLICATION FOR PERMIT y ' SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA RECOVE D Telephone (209) 456-6781 MAY 2 9 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY . Q (Complete in Triplicate) PUBLIC HEALTH SERVICES VVIR�N( Es•1TA�H A,& R&IS10N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal hew rk erern escnbe T rs application 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. I i Job Address City Lot Size. PM i Owner's Name Address Phone CK Contractor J� Address Z901 LiCense No, hone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ `SYSTEM REPAIR ❑ - OTHER ❑�� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITSISUMP 'i� . I C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavation la. of Well Casing ❑ Domestic/Priv+ hS G aIvel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Ota�her ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installe y Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') .E DeptFll Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION l 1 DESTRUCTION { I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Reside1 ce_ Commercial_____ Other Number of living units:. 'pi Number of bedrooms w, Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ X11 Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size ikl FILTER BED ❑ Distance to nearest: Well Foundation Property Line I i SEEPAGE PITS ( I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I�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 agent'sisignature certifies the following: "i certify that in the performance of the work for which this permit is issued, 1 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." I The applicant must call for all rerquired inspe 'ons. omplete drawing on reverse side. �. Signed X Title: . 6,-�,PA AV,L C;04— Date: J� FOR Dl_PA.RTMENT USE ONLY i i n Accepted 1 A"I cat w epted by Date Area_ Pit or Grout Inspection b 6Jate .Date� -�-- r,��- —/ aminal lnspect/i�on by/ /;� Date Additional Comments: /raj l Y►i �l /6ki4n/(J V'l S/� '` //7✓ /�EI,.k ❑ Stk 466-6781 D Lodi j 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies tot'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 P FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y DATE PERMITNO. INFO C a.EH13-24(REV.1 i n 5) EH 14-29 '� � 'p4] r ra 90 �o�