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PCjWT'�44ED _ APPLIC-ATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 L& PERMIT EXPIRES 1'YEAR FROM DATE ISSU {� (Complete in Triplicate) ��+ 1989 � Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work etein,described.Th is on is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and � Lwr � �n J quin Local Health District] PERMIT/SERVICES Job Address 1 1 3 3L Yrs wy City. Lot Size PM of Owner's Name Address Phone + / l Agip l Contractor +C Address I 46 Jf 4f Js! AA()�`�'License No. Phan. 4 93 1-3 5' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION (2N SYSTEM REPAIR 0 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 SPECIFICATIONSk. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public ❑ Other I-1 Delta Depth of Grout Seal Type of Grout - . 1d Irrigation —..Approx. Depth i I Eastern Surface Seal lnstalled by _ Repair Work Done ❑ Type of Pump H.P. C292 61? -- State Work Done, Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth '.Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION ( 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 Capacity No. Compartments PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property.Line L LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size_ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,'kate laws, and rules and regulations of the San Joaquin Local Health District- " f 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)`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: '9 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 mlqst call all required inspections. Complete drawing on reverse side. [ Signed X Title: Date: FO ARTIVII US ONLY Application Accepted by /';M Date v Area Pit or Grout Inspection by .Date Final Inspection by Date -/ L{e Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT]REMITTED CASH RECEIVED BY DATE P/E]RM�ITI'NO. +.EH14-2BIAEV.iiH5i -If—U 1 �'Ifi-5 /I/ .. .. t '