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APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT C(OPY 1601 E. HAZELTON AVE., STOCKTON, CA66-6781 RECE1VEt� Telephone 1209) 4NOV 21 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDSAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES P P ENVIRONMENTAL HEALTH '�/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. 11SSl9Alication 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 J 07 /V 5CffV6C- City Lot Size6�/-7 PM Owner's Name tom. 00VO �-Al IJE0eq Address l`�� 3o)( o •wOba&01'D� l��c�6(A. Phone Contractor ! r Si1 a /o/b to RK �� ddress WDO D,EIIf� (14, 3� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Y 56(1. WIM 6 C6) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public XI Other'W(IJ& Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth t 1 Eastern Surface Seal Installed by _ Repair Work Done O Type of Pump H.P. State Work Done Well Destruction O Well Diamet r Sealing Material (top 501 Depth Filler Material 18elow 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 6 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.O 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 1 I Depth Size Number SUMPS O Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 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."Contractors hiring or subcontracting signature certifies the to4owing:"1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant, U call for all required inspections. Complete drawing on reverse side. SEF ,.¢-rn4Cjf.c_P., Signed Title: G��G9N - Date: r �/ _ FO DEPARTMENT USE ONLY G/,,,, /► Application Accepted b)y'rrKl"�`^'ZaADate l C� /dy Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6281 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- F,atum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. r EH 13.24[REV.I/R51 0otr EH.24 -�