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APPLICATION FOR PERMIT D � 7� SAN JOAQUIN LOCAL HEALTH DISTRICT �3f 1601 E. HAZE T ON AVE:, STOCKTON, CA Telephone {2091 466-6781 AUG 6 1988 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIROMENTAL HEALTH PERMIT/SERVICES 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. ` AlI _c`� 4 Job Address �• Al ! & � City �+ Lot Size PM Owner's Name Address ___ P ono f� Contractor. &* ddressb�G License No. hone 1 TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE J- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing wuomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout .—. E I Irrigation —..Approx. Depth _J I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done _ v Well Destruction ❑ Well Diameter, Sealing Material (top 501 Depth I Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is I 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: 1 Water table depth r SEPTIC TANK , ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. 0 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 Propeny Line t _ SEEPAGE PITS I I Depth Size Number f SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t _ 1 hereby"cenify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander rules and regulations of the San Joaquin Local Health Di1trict. 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 applicnz, t call f II required inspections. Complete drawing on reverse side. p �r Signed X �. Title: l Date: 6 p. FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area C 4-- y .� L &� __7� i Pit or Grout Inspection by Date Final Inspection by Dai�Q i Additional Comments: , ❑ Sik 466-6781. EJ 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 FEE INFO AMOrhU�NT UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0 +.Em 13-24(REV.IJ K5) �. lY F Pfl P �g•�! EH 14-29 llllll 8 D i l