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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' ' 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 OCT 16 1989 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH ' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herbiTl'if�Sations of the pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wellJpump and the Rules and Regulations of the San Joaquin Local Health District- Job Address SZ, 3- City Lot Size PM 1 t- Owner's Owner's Name Address Phone c.� I Contractor r •Address �`o �A1Q Cl (cense N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ `SYSTEM REPAIR OTHER ❑ 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 [__1 Industrial LIOpen Bottom ElManteca Dia- of Well Excavation Dia. of Well Casing Aomestic/Private ❑ Gravel Pack ❑ Tracy / Type of Casing Specifications FI Public n Other ❑ Delta f f�Depth of Grout Seal Type of Grout . I 1 Irrigation __Approx.,Depth- I II Eastern ? ft,,Surface Seal installed by - Repair Work Done Type of Pump H.P- ?T - - State Work Done _ Well Destruction. © Well Diameter Sealing Material ftop 50') Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDI,TION f I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) i" F �- ' Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth -SEPTIC TANK Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Will —Foundation — Property Line .r LEACHING LINE ❑.No:"& Length of lines -,Total length/size FILTER BED �❑ -Distance to nearest: Well Foundation Property Line SEEPAGE PITS NI-1 Depth Size Number SUMPS 0 Distance to nearest: Well`. Foundation 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 I rules and regulations of the San Joaquin Local Health Di$trict. %, Home owner or licensed agent's 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."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 applican it for ail re4pirgo inspections. Complete drawing onreverseside. �, I Signed X Title: f�-�a A Date:0-7 FOR DEPARTMENT USE ONLY Application Accepted by Date /40" tea Pit or Grout Inspection by Date Final inspection by e f a Additional Comments: d Stk 466-6781 Cl 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 FEE AMOUNT DUE AMOUNT REMITTED _CASH RECEIVED BY DATE PERMIT'NO. INFO '. +.EH13-24(REV.r/K5I 3,5 96-1?50 EH 14-26