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E ry-_RISS, r-l-N APPLICATION FOR PERMIT a24 � SAN JOAQUIN LOCAL HEALTH DISTRICT NOV 2 9 1989 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMITISERVICEJ (Complete in Triplicate) 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 �! l /J I�D'1 �! City a�� Lot Size N.61144c, PM Owner's Name ' w Address ` � �WwpaE�5 0944r4f r, Phone '7917- 071 N 6-WA eJr_4W 94S-6 tD i Contractor [ • Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i PUMP INSTALLATION SYSTEM REPAIR 171 OTHER L1DISTANCE T0O NEAREST: SEPTIC TANK 1.0p 'J`$EWER LINES AVa6 DISPOSAL FLD. PROP. LINE. ' FOUNDATION AGRICULTURE WELL OTHER WELL �` PITS/SUMPS gY'------INTENDED-USE -TYPE-OF-WEL-L!`-PROBLEM AREX- CONSTRUCTION SPECIFICATIONS-'- 0 PECIF1CAiTIONS-'-❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Fl Public 17110ther ❑ Delta Depth of Grout Seal Type of Grout__. X Irrigation --Approx. Depth I i Eastern 7 Surface Seal Installed by Repair Work Done ❑ Type of Pump 7601- H.P, 71 State Work Done Well Destruction ❑ Well Diameter Q r11 Sealing Material (top 501 «iM-r- 80" I411�r1N Jrr16..-. Depth Z-q.5 f Filler Material leelow 501 4 - r' _ TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIRIADDITION i I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet.) i 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . �1 hereby certify that t 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 t 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 inspections. Complete drawing on reverse side. Signed X Title: Date: F W 4 MENT USE ONLY Application Accepted by Date c�.t7 Area 4;�11 Pit or Grout Inspection by Date Final Inspection by Date�� Additional Comments: ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED ASH "AECEIVED BY DATE PERMIT'NO. +-EH13-241REV.I/n 51 3�d 0 o , l EH 14-tet