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APPLICATION FOR PERMIT QpAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 FEB 15 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUMN JOAQUIN COUNTY (Complete in Triplicate) Funir, HEALTH CJERViCES ENVIRONMENTAL HEALTH uiiliSION Application is hereby made to the San Joe uin Local Health District for a permit to construct and/or install the work herein described, This application is made incompliance w' oauin C qoun Ordnance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health p' /3�I IC�E�l.i! Z�T6 X CCS Job A(Name / ,� City Lot Size PM r OwnerS `-� Q-s C-��°`'Address �� ' ��'L� Phone —/ � Wei H0,;✓mat�Dr r 1I I nJ 33 + 9eta (o34r-71L Contractor_ ..�: Address v I License Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / . i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑/(JIQWI "/�./ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1<�)6 / t Q -/DISPOSAL FLD.� 6PROP. LINE AIna 9` FOUNDATION $a AGRICULTURE WELL ! . OTHER WELLZda PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G� A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ OtherDepth of Grout Seal Type of Grout�d✓C ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by a�fd Repair Work Done ❑ Type of Pump _ H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 50') r Depth / Filler Material (Below 501 + {31 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is ') available within 200 feet.) Us 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 -75 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line J LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 District. I p 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 issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections, Complete drawing on reverse side. Signed X 7 Title: 5�,A- Date: ^�� OR DEPARTMENT USE ONLY Application Accepted by Date C;� ea -63 a r Pit or Grout Inspection by � Date Final Inspection t' ate I Additional Comments: ❑ Stk 466-6761 ❑ 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$ RECEIVED BY DATE PERMIT N0. INFO CASH + EH 1324IREV,t/s51 EH 1426