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N �Zc APPLICATION FOR PERMITRECEIVO j SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,--STOCKTON, CA AUG 16 1990 Telephone 12091 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVIC'ES (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. A Job Address ` City Lot Size PM I t? I Addres� Phone Owner's Name �h ti ContAddre Con—tractor ss ense No. Phone ;i �- 7 :. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS RUC �- .INTENDED USE TYPE OF WELL T PROBLEM AREA CONS T1ION.SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private +❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`l Public � - +��rt•n Other � ❑ Delta Depth of Grout Seal Type of Grout - igation —_:_Approxi"Depth (.Vastern S rface Seal installed by Repair Work Done ❑ Type of Pump � H.P. State Work Dane _ Well Destruction L) Weil Diameter Sealing Material )top 50'! k pepth Filler Material 16elow 501 -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 2DD feet.! i Installation will serve: Residence. Commercial F Other Numoer of living units: Number of bedrooms` Gharacter l• ler of sail to a depth of 3 feet: + Water table depth SEP lI iT'ANK ❑' Type/Mfg Capacity No. Compartments r t PKG. TkEATMENT PLT. 6V;- ,. r, Method of Disposal t .. �, as Distance to nearest: ,—Well Foundation Property Line LEACH G LINE ❑ No. & Length of lines Total length/size FILTER BEd ❑ Distance to nearest: Well Foundation Property Line SEEPA E PITS i I Depth = Size Number i SUMPS ❑ Distance to nearest: �,'Well Foundation Property Line DISPO AL PONDS ❑ ' _ YI hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander rules anjd 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." Contractor's hiring or sub-contracting signature certifies-the following:"I certify that in the ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion"laws of Calitorni .' : The applicant mus c I r all re uired s ction . Complete drawwing on Signed X Title: 7f0 -DEPARTMENT'USE-"ONLY — . r Application Accepted by Date Area Pit or Grout Inspection by Date final Inspection by DateZS i Additional Comments: kik ❑ 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 r FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH +.EH13-241REV.tiH51 � �^ EH t4-26