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APPLICATION FOR PERMIT 40 PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA MAY 2 9 1989 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE SAN JOAQUIN COUNTY PUBLIC HEALTH SFRVICCS (Complete in Triplicate) ENVIRONMENTAL HEALIH DIVISION 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 40,4", `S��Klvv� J y• City PDO& Lot Size « mQ PM Owner's Name 58vt— �Q Address !'�1 �� Phone !�9_�� f 1 Contractor t/i((16wnitr' 4t4Zuk-,6-1 S Address License No. Phone TYPE OF WELL/PUMP: NEW WELL Qt?-I9 WELL REPLACE NT ❑ DESTRUCTION ❑ N�,, PUMP INSTALLATION SYSTEM REPAIR E] OTHER O ,�L ACLP DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFICATIONS —�A❑ Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavation ra. of WAi. C7 Domestic/Privat�j� ttA Gravel Pack C7 Tracy Type of Casing Specifications f"I Public (1 Other C I Delta Depth of Grout Seal Type of Grout I I IrrigationApprox. Depth I I Easterh Surface Seal Installed by Repair Work Done ❑ Type of Pump — H.P. __- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 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_ 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 SUMPS Ll Distance to nearest: Well Foundation__ Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 inspections. Complete drawing on reverse side. Signed X _ Title: A/q` � Date: FOR DEPARTMENT USE ONLY Application Accepted by 4p""� U — Date Area Pit or Grout Inspection by Date Final Inspection by / Date Additional Comments: _ 13�ro 0 4r,�m ,j ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20119, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT N0. . EH 1324(REV.i/R 5) �� , EH 14-20 V �7/q.