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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 FE B 15 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUSON JCAQUIN COUNITY'. • {Complete in Triplicates P IC HEALTH SERVICES . EN\fIRON MENTALHEALTH DkVISION 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. Job Address 42 Z11 k4/ /r fZJ,.RAIZ. `1`"4-- _ City S /moo" Lot Size z,:5'0 PM ' Owner's Name ��l� � � �'� Phone ~f - WCS Imo-a�1mai'Vr t I irl r� 3 33 -I- 9ec� ld-p-u g5'I4.2 4r-7-1 Contrac- dpi Address L v — , License - Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑NIC:w, DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES /dQ f DISPOSAL FLD.�QO� /r1 PROP. LINE d , FOUNDATION 5a AGRICULTURE WELL ✓�� OTHER WELL Id6 PITS/SUMPS W INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q ❑ Domestic/Private ❑ Gravel Pack U Tracy - Type of Casing Specifications OC1 ❑ Public ❑ Other. QVi-,4V_A�Aelta Depth of Grout Seat Type of Grout�Cyl/C F. ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by - ,_r- > �•� ' Repair Work Done ❑ Type of Pump . H.P. State Work Done Well Destruction ❑ Well Diameter /� Sealing Material (top 509 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) 3 (f) 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE It No. & Length of lines Total length/size 'x FILTER BED Ll 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. :. 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 edd inspections. Complete drawing on reverse,side. �� Signed X �� [_�f' �� __ Title:- ��" �/ Date: r �~�" OR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _- ❑ Stk 466-6781 d 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE GG�� GPERMIcTNp. +EH 13-24(REV.1/86) EH 14.28