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APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 MAY 2 9 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEAI.TH SERVICES �VyIRgN%RT%HEALS �IVISION HT Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal 11 w rk ein escrrbe is 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 5aktL <1L,9 1�V. CityLot SizePM-- Owner's Name `� �� li' [r �t� Address`` ff Q 1 t_1_�1� Phone co Contractor (! 'Address cense No. 9PIV hone _ TYPE OF WELL/PUMP: NEW WELL D/_ �U WELL REPLACEMENT F1DESTRUCTION [_1 PUMP INSTALLATION ❑ C!' SYSTEM REPAIR ❑ OTHER ❑ (jfC DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑//Open Bottom ❑ Manteca Dia. of Well Excavation ra. of Well Casing I-1 Domestic/Priv '; IWI Gravel Pack El Tracy Type of Casing- Specifications F) Public 1-1Otherfl Delta Depth of Grout Seal. _ Type of Grout I I Irfigatior� — Approx. Depth I I Eastern Surface Seal Installe y Repair Work Done U Type of Pump _ 11.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 I I DESTRUCTION 1 1 (No septic systern 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 Cl 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 U 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 Di3trict. 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, 1 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 inspec'onsj omplete drawing on reverse side. Signed XTitle: j�� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date `s Area Pit or Grout Inspection by 4 f Date- Fin,/al Inspect/icon by Date Additional Comments: 1 �Z a�J( '14 ! %2y. 'W,-// f] Stk 466-6781 ❑ Lodi 369-3621 O Manteca-823-7104 ❑ Tracy 8351385 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 C RECEIVED BY DATE PERMIT NO. INFO EH 1324(HEV.ries) EH 142E 'per �� q, qL-u