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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICTG k �� ?�� { 1601 E. HAZE T ON AVE. STOCKTON, CA Telephone (209) 466-6781 mai 1 Ib 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) g_,RMt I Si~WCES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address ��1/J �/ !Q'tL�� - City Lot Size PM Owner's Name Address l tN' Phone ContractoOEL ` C� ` Address - ib 1? s3o License No.q:53?6D— Phone 3 /r TYPE OF L/PUMf, -,—NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack f ❑ Tracy Type of Casing Specifications F] Public ❑ Other + ❑ Delta %=Depth of Grout Seal Type of Grout - I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. 1�+2�_ State Work Done Aa Well Destruction ❑ Well Diameter 4"^'Sealing Material (top 501 _ Depth Filler Material (Below 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAMIADDITION I I -DESTRUCTION I i 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 0q 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 LEACHING LINE ❑ Aro- & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size — Number TSUMPS__ 0 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 Ds%ttict. - Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not p 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 ersons subject to workman's compensa- tion " fy pe P p Y P J P tion laws of California." -{ The applicant m alb for all requir d inspections. Complete drawing on verse side. Signed X, Title: / Date: N 1\" /; ,y/FOR DEPARTMENT USE ONLY � / AO/Application Accepted by r Date Area Pit or Grout Inspection by Date Final Inspection by Date { I 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO +.EH 13.24•IREv.tin 51 S EH 14-26 f