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i k � - APPLICATION FOR PERMIT RECEIVED . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA ,JUN 2 2 1$90 Telephone (209) 466.6781 r PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No,549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. l i Jab Address � City:�� Lot Size PM c— , Owner's Name — ' " s Address _ �s�1rs � � T� Phone t~ _ Contractor Lel tR�t �Qress 1 %� ee 42OLgense No.�,34,6 2_phone Z. / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ft D. 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 t-gomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 171 Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout _ iI I Irrigation �.-Approx. Depth I I Eastern Surface Seal Installed by Repair Work bone Type of Pump ... H. it 440, P, — State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 5011 Depth Filler Material(Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 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 r 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 if -BEACHING LINE S ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 rules and regulations of the San Joaquin Local Health Dittrict. 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 shag not r employ any person in such manner as to become subject to workman's compensation laws of California,"Contractors hiring or sub-contracting signature certifies she following:"I certify that in the performance of the work for which this permit is issued,I shall employ door's s subject to workman's compansr tion laws of California." 1 'The applicant must all f aH required p' spactions. Complete drawing on reverse side. Signed % Title: et-- O Date: OR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Data Final Inspection by Date_IL!9� Additional Comments: I! ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Pofmit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95MI FEE I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE E-Ilk9 O. +-Erf 1 3-24fRtV.r�xsr EH 13-2a o l