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r - t APPLICATION FOR PERMIT SAN JOAQUIWLOCAL HEALTH DISTRICT "ENFE m"' 1601.E. HAZELTA AVE, STOCKTON, CA ' 2 466-6781 ' y: .. .''`" Tekephorle f t PERMIT EXPIRES 1'YEAR FROM.,DATE ISSUED DEC fi 1989 (Complete in-Triplicate) E;NV;; , ; ,;i NTA). HF H r �CBtF{)r1 IS Application is hereby made to the.San Joaquin Local Health District for a permit to construct and/or install the work�Fl�r j'r ti made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules an e 'up, ti �f Joaquin Local Health District. i Ili Q/�f if �.3 t I Q r ' City Lot Size PMS Job Address J; Address / !�� Phone Owner's Nam --��— _ t ...-Contractor N dress aO ;!!?0,y /12,7—License f�o�� `� Phone ^ �� G TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION LlSYSTEM REPAIR 171OTHER 17 DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } I INTENDED USE TYPE OF WELL P,R013'LEM AREA, CONSTRUCTION SPECIFICATIONS i ❑ Industrial- ,. ❑FOpen-Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing ❑ Domestic/Private ❑ GT v`el'Pack�' " ❑{- cy 3�' '.� ( Type of Casing Specifications } - } , . f 1 Public ., f=}-'Other,..-� _n_-Delta �- Depth of Grout Seal Type of Grout f - ! I Erri atiori Approx. Depth l l stern S`jrfp, E" Saul Installed by 4 g �/ H.P. 1.�.4 i + State Work Done Repair 1lVar'6(3one Rr Type of Pump HP1� Well Des fiction 1-1WellDiameter h am+ Sealin- Material Stop 50'k) f 1.11' t ' I Depth '* __ Filler f aterial (Below 50') - r TYPE OF SEPTIC WORK: NEW INSTAtLATIONIlT REPAIRIA[IyDITION l I DESTRUCTION i I (No septic system permitted if public sewer;is, ' J available within 200 feet.) Installation will,4rve: Residence Commercial_ Other + � Mfr•` _ ,V Number of living units: Number of bedrooms 6 I Water table depth Character of soil to a depth of 3 feet: ll r SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments yPKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well } Foundation Property Line t i LEACHING LINE Cl Noo. & Len th of lines # - Notal-length./size—------- -- — E FILTER BED ❑ Distance to_nearest: Weir _ Foundation Property Line 16 SEEPAGE PITS 11 Depth Size !� Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS y# 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 f rules and regulations of the San Joaquin Local Health District. Home owner or ' nae nt'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 rson in such nner as to become subject t workman's compensation laws of California." Contractor's hiring or sub-contracting signature. . certifies th following: "I cart y that in the or ne a work f this permit is issued, I shall employ persons subject to workman's compensa tion laws of GalI or ia." The ap icant mus c all req a /, ompiete Cawing o a id Signed ` / Title: Date: /O [ OR DEPARTMENT USE ONLY I Application Accepted by Date Area Pit or Grout Inspection by ato Final Inspection by Date s" Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 i FEE AMOUNT DUE AMOUNT REMITTED 4 CASH RECEIVED BY DATE PERMIT NO. m INFO - �.EH 13-24(REV.t/Kb) � �Z EH 14-2a J J