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w !I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 4 1601 E. HAZELTON AVE., STOCKTON, CA J� Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED MAY 18 1990 �I it (Complete in Triplicate) rrNN Il Application is hereby made to the.San Joaquin Local Health District for a permit to construct and/or install the JN ication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules San Joaquin Local Health District. °I Job Address rl City Size PM Owner's Name,l.,,A JALt 5J Address Go-u^-^- Phone ,i Contractor0 Address ! 2 License fro Phone _ TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP)INSTALLATION ❑ SYSTEM REPAIR Ir OTHER ❑ ,i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .1I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing h 1Y Domestic/Private C) Gravel Pack ❑ Tracy Type of Ca"sing Specifications I ❑ Public i l Others❑ Delta Depth of Grout Seal Type of Grout i I Irrigation --Approx. De th 1.1 Eastern Surfa a Seal Installed by ' ' Repair Work Done X Type of Pump - H,P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 50'1co u Depth___ Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted if public sewer is d available within 200 feed Installation will serve: Residece— Commercial_ Other l I iNumber of living units: Number of bedrooms 1 Cha after of soil to a depth of'3 feef; `•, # Water table depth SEPTIC TANK CDType/Mfg " '` Capacity + No. Compartments 1 PKG. TREATMENTPLT, ElI� ' '' """" Method of Disposal Distance tance to nearest: Well �Foundatin' hr� t Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ` 4' FILTER BED ,w❑_,.Di�Mtance to.nearest:. . Well Foundation Property Line i SEEPAGE PITS { I Depth -Size - _ Number II SUMP 5l ❑ 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 ` i rules and regulations of the San'Joaquin Local Health Diltrict. Home,avvner 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 nat employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the fallowing: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- tion laws of California." I� i The applicant c 11 for all required in ctions omplete drawing on reverse side. I Signed X I� Title: Date a I14R DEPARTMENT USE ONLY i Application Accepted by' I®i� r - �- _ Date L Area Il Pit or Grout Inspection by 'bate Final Inspection by Date I) f Additional Comments: u ❑ 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 .h I IFEE CA NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. +IEH53-24IREV.i/n51 EH 14-26 /