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APPLICATION FOR PERMIT tic v AN JOAQUIN LOCAL HEALTH DISTR CT PAYMENT SNF \S, 1601 E. HAZEL i ON AVE., STOCKTON, CA RECEIVED �00� , °�� `?' Telephone (209) 466-6781 DEC 14 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p ENVIRONMENTAL HEALTH ili �..� (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 desPERMITf9Efd0"5n 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. Job Address 1/0he ylo J �/ City,✓ �G �10 Lot Size PM q Owner's Name 7i� � � _ __ Address 1110AI hif�� 114fW5 Phone 600411vdu,-4/r� 18.12 T,esBUTF.� x/r�G �� Contractor ;F110040o( 171115• Address 40 gTg'is License No.,V914/3IKO Phone l TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 Ty ER C-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 7121 FOUNDATION ��tr— AGRICULTURE WELL OTHER WELL$, PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z0 i/L. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Re— D•vA40 I/L. Specifications ('1 Public4. a( /61Other /Vbx[1 Delta Depth of Grout Seal '}27� Type of Grout _ I I Irrigation 6LrCZLS Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done E Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 s Depth Filler Material (Below 501 —_ S TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 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 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 L. SUMPS Ll Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS Ll f7p 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 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 of the work for which this permit is igA"' `[�'g�ipensa- tion laws'of Californ J �1 ENVIRONMENTAL HEALTH DIVI ION The applicant st all for all tions. to drawing on reverse side. ECIp PERM Signed Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by Date r 49/ Area Pit or Grout Inspection by Date Final Inspection by ` ``t Gt Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 CASH RECEIVED BY DATE PERMIT'NO. INFO r q + EH 13-24(REV.1IHs) �� EH 14-26 1 1