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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTn 1601 E. HAZEL T ON AVE. STOCKTON, CA V Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 2 1989r (Complete in Triplicate) 1.; Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described: This applidi`ion is made in compliance with San Joaquin County Ordinance No. 9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. (rAIJrn Job Address �N,� /►FdI�K City Z AWACAI Lot Size PM Owner's Name _Zkl 2/LZZZ1 Address / 7 !f77 Z T _QP Al�i_ Phone / +n � Gill 7-42-' �/�r� � � Contractor _" Address Zra G/l/1.G�iL License No. �2 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XfJ5P A-eF_PSYSTEM REPAIR ❑ OTHER C 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 Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public (a Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.Approx. Depth I I Eastern jou f ce Seal Installed by Repair Work Done ❑ Type of Pump H.P. J rlK�r State Work Done �- )SWF Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ Type/Mfg Y 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 ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I DepthSize Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 applicant t req ns. Complete drawing on rev side. Signed Titift; Date: FORD PAR ENT USE O LY Application Accepted by Date ,9e--P7Areaza Pit or Grout Inspection by Date Final Inspection by Zv Date 13-30-K Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. a.EH 13-241REV.1/85) � EH 14-28 !