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w APPLICATION FOR PERMIT Fm;;E I E D SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 0 f 1990 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES + (Complete-in Triplicate) 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin' Local Health District. + t ` Job AddressCity Lot Size PM f .� Owner's Name �,�-_=----- Address !� Phone ContractorpW e �` r 9ddress & gj;r r� jt=Q`53�ic�nse No.164Pg6Z Phone S:as "_2q TYPE OF WELL/PUMP: 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 PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ("1 Public ❑ Other s f] Delta Depth of Grout Seal Type of Grout I I Irtigation —..Approx. Depth I I Eastern 11 Surface Seal Installed by I Repair Work Done 1t--Type of Pump-�,� H.P. Vim- State Work Done JF Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RFPAIR/ADDITION I I DESTRUCTION I I {No,septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tab4e depth SEPTIC TANK ❑ Type/Mfg Capacity � r No. Compartments r- PKG. TREATMENT PLT. C7 Method of Disposal f 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 Depth Size Number SUMPS 1=1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that 1 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 bfAhe work'for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." k i The applicant must call r all required 'nspections. Complete drawing on reverse side. pp Signed X Title: _ Z"-- Date: � OR ARTMENT USE ONLY Application Accepted byDate &Ir�j / Area / Pit or Grout Inspection by Date Final Inspection by Date rA7 70 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy' 835-6385 , Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 200.9;Stk.. CA 95201 FEE INFO AMOUNT DUE AMOUNT-AEMITTE0 CASH RECEIVED BY DATE PERMIT'NO. ..EH 1324 JAMi/A5) / +Z-92} 0 �� EH 14-29 v x4f CJ