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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (2.09) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 9 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in �� I��A�TH SERVICES made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/ um �r`r�nA�r �IQ(�(��Ircation is Local Health District. g P P and egulations of the San Joaquin Job Address City./1 W IJ f 1^ Lot Size /f-!2pM — Owner's Name gh- C Address ��-- � / Phone Contractor -KGG'� Address �^fLicense No. . Phone TYPE OF WELL/PUMP: NEW WELL �'`{..� WELL REPLACEME F DESTRUCTION O PUMP INSTALLATION CJ SYSTEM REPAIR CJ OTHER 0 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 r C7 Industrial / 0 Open Bottom O Manteca Dia. of Well Excavation _ Dia. of Well 0 Domestic/Privalp' ❑ Gravel Pack ❑ Tracy Type of Casing___ —__ Specifications F) Public y FI Other I I Delta Depth of Grout Seal _ Type of Grout I Irrigation __-,Approx. Depth I I Eastern Surface Seal Installed by -------------- ---- Repair Work Done Ll Type of Pump H.P. _ — State Work Done Well Destruction O Well Diameter Sealing Material (top 50') Depth _ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence._ Commercialseptic Other_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth---.___ SEPTIC TANK O Type/Mfg _ Capacity___ No. Compartments PKG. TREATMENT PLT. (7] Method of Disposal Distance to nearest: Well Foundation ------- Property Line _ LEACHING LINE Ll No. & Length of lines _ Total length/size FILTER BED (_1 Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS ( I Depth _Size___._ —_- ___ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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 Diktrict. 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 ins ctions ornplete drawing on reverse side. Signed X Title: ` G Date: FOR DEPARTMENT USE ONLY Application Accepted by -�— Dated Area / , _- Pit or Grout Inspection by DaetFinal Inspection by Date 04'[aAdditional Comments: 1 J,/��jAtI4 0 _ -,e04- 1.1 Stk 466-6781 0 Lodi 369-3621 O 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 CK INFO CASH RECEIVED BY DATE PERMIT NO. EH 1324(REV.r i x sr EH 14-26 III 1 2S