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APPLICATION FOR PERMIT 10 --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 2 9 1989 (Complete in Triplicate) SAN JOA UINCO UNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t , H LT TEV'CC� • made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and t �Q(� d �7' Jf ion is t e n Joaquin Local Health District. / Lry� � �� 1 �C/1 V �Ir/ City R � Lot Size - Job Address � O'LC.V 4, PM Owner's Name .�,5�� Address r_._$'t/` Phone Contractor zl& / t�j�r y Address r.� 'license No. Phone TYPE OF WELL/PUMP: NEW WELL IV �b-ZS WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLO. PROI LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,per ❑ Industrial ❑ an Bottom ❑ Manteca Dia. of Well Excavation ---�`J p. of Well Casing _ (_l Domestic/Priv Gravel Pack ❑ Tracy Type of Casing Specifications ['I Public nOther fl Delta _ Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Sufiace 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 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence _ Commercial__ Other available within 200 feet.) 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 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 Di§trict. 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 ions. omplete drawing on reverse side. Signed X Title: 2� Date: R DEPARTMENT USE NLY Application Accepted bybate ✓v ,Z1(� Area Pit or Grout Inspection by Date FinalInspection by / Date ��g Additional Comments: ICI �«/" ✓ �✓ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNTDUE AMOUNT REMITTED K INFO C RECEIVED BY DATE PERMIT'NO. EH1211REV.,iNS) EF,,.426 0 3