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' APPLICATION FOR PERMIT • PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT kA 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 mAY 2 9 1989 PERMIT EXPIRES_ 1 YEAR FROM DATE ISSUEIIAN JOAN UIN COUNTY (Complete in Triplicate) PWkIC HEWH SERVICES ENVIRONMENTAL HEALTH 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 S City Lot Size 52nePM _ Owner's Name _ Address f �, -__>� 7Phone � Contractor ddress L�f(fnse No. PhonejV TYPE OF WELL/PUMP: NEW WELL WELL REPOCEMENT DESTRUCTION O PUMP INSTALLATION ❑ //y SYSTEM REPAIR ❑ OTHER O n 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 yC�R ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well ❑ Domestic/PrivatCl Gravel Pack Cl Tracy Type of Casing Specifications I'I Public ��'f9 f 1 Other [_1 Delta Depth of Grout Seal Type of Grout I I Irrigation (!� _.__. Approx. Depth I I Eastern Surface Seal Installed by Repair Work one [_7 Type of Pump H.P. _ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. [I Method of Disposal Distance to nearest: Well Foundation _ _ Property Line LEACHING LINE ❑ No. & Length of lines Total length/size— FILTER BED [.l Distance to nearest: Well Foundation Property Line_ SEEPAGE PITS I I Depth _Size Number SUMPS 11 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 m t call for all required 1 sp ions. omplete drawing on reverse side. Signed XTitle: Date: FOR DEPARTMENT USE O LY Application Accepted by Date �' r Area__ 4 Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: Ll Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-638 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 RECEIVED BY DATE PERMIT NO. INFO SH 1 EH 132 (REV.tiN5) EH 1429