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APPLICATION FOR PERMIT ' �Whl JOAQUIN LOCAL HEALTH DISTRIC.. NOV 2 7 1989 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRONMENT HEALTH I Telephone (209) 466-67$1 qIu � �'r�l_,T H Pk.R M I T/SERVa PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;i,c (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct :i i escribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 forT- ,Job /pum ,and }e'A" an egulations of the San Joaquin Lucal Health District.Address 9<>3 ocur, t c.S �� City Sk�l�k' Lot Size f Z�x PM Owner's Name ��`�^ 1 'ri Address 2-Z -c. "} �'� r�� 5�octc' 't- Phone 1477- (2<;" Contractor UtIY �3c:.c,� � Address Z�Z77� `� �''' License No. 4 �� 7`� Phone V-7- S74 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER r.5S INSTANCE TO NEAREST: SEPTIC TANK SEWER LINES .2-0 DISPOSAL FLD. PROP. LINE (u FOUNDATION 7y AGRICULTURE WELL — OTHER WELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Public 171 Other 11 Delta Depth of Grout Seal'kkt �F �=�r>,c i Type of Grout _ Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by 01,Wt Ty -NK GCs�+s.�7�fr1�,a f4ve4-� P(epair Work Done 17 Type of Pump H.P. State Work Done Wrlt Destruction E7 Well Diameter Sealing Material (top 50.1 Depth Filler Material (Below 501 _ IyPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo 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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I EACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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- lion laws of California." Tho applicant must call for all required inspections. Complete drawing�on reverse side. Signed X , v,J Title: Gt+✓�"Y2eei� �Ctnf � �Y-� Date: 7, -,A TMENT USE ONLY Application Accepted by - Date/ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I I 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. • EH 13 24(REV.r/"5) EH 1n 20 ��v CLi I �\ C