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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED (Complete in Triplicate) MAY 2 9 ^r1989 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install e1 Nks application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump apd. r� 6{Jdrf�WESSan Joaquin Local Health District. CIV ENTAL�HEALI'H DIVISION Job Address /7 Z �C�+�V i� Sync �. .' City Lot Size �MpM Owner's Name:5Isd 0- �-'�!lPf (40 Addresss_�� j �l Phone Contractor Address �( eL�cense No. F h 716 TYPE OF WELL/PUMP: NEW WELL Vob 21 WELL REPLACEMENT-r] DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �y(slP DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/S MPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ia. of Well Casing L1 Domestic/Priva ❑ Gravel Pack ❑ Tracy Type of Casing-_ Specifications FI Public fA Other ❑ Delta Depth of Grout Seal Type of Grout I 1 Irrigation _ _.Approx. Depth I I Eastern Surface Seal Installed by Repair Workone 11 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Ntl Depth Filler Material (Below 501 _ (` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REFAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is U available within 200 feet.► w 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. Cl 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 __ Y 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 y rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "1 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 inQoct000d. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by alk�� Date 461- Area Pit or Grout Inspection by /f1 Date Final Inspection by ^Date Additional Comments: yyf jig oedJlg !/gB oA'**' A&i r,Z ❑ Stk 466-6781 ❑ 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 AMOUNT DUE AMOUNT REMITTED K INFO RECEIVED BY DATE PERMIT NO. EH 13 24(REV.rin61 EH 11-2d � r