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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone {209) 466-6781 MAY 18 1990 ?,,—,n iv,Pa.ul PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I. (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work h�� rplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an egu ations o t e an Joaquin Local Health District. i � J Job Address DQ� City Lot Size PM Owner's Name Address �_(!y_✓'r` Phone64 J f Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR K 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 C1 Manteca Dia. of Well Excavation Dia. of Wel; Casing V Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ,j ❑ Other Ll Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx.,.DeDtb l J Eastern Surface Seal Installed bye2 _ Repair Work Done ,I Types p H,P. _ -'___ _._ State Work Done �- Well Destruction ❑ Well Diameter t Sealing Material (top 50') Depth Filler Material fBelow 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I ] DESTRUCTION I ] (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 ' 4 Character of soil to a depth of 3'feet: t •"3" ' 'Water table depth SEPTIC?TANK ❑ Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT. ❑ � ? Method of Disposal S 4 Distance to nearest: Well Foundation Property Line +,o :r �. � r� ..r... LEACHING LINE ❑ No. & Length of lines -' Total length/size t FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS l I Depth . Size _ Y Number f r Foundation Property Line SUMPS Ll Distance to nearest: .� 1NelI """ 1-t �1 '-� � 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 j 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 r certifies the following: "I 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 must call f r all required in coons. mpl drawing verse side. 1 Signed X Title; Date: R DEPARTMENT USE ONLY 1 Application Accepted by DatefArea Pit or Grout Inspection by Date Final Inspection by I Additional Comments: ❑ Sik 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 CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. I# +.EHt3-24 IHEV.r/n 5Y O Q_4 € EH 74-28 ( r 6 - y .r•c