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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �'E I V E I 1601 E. HAZEL i ON AVE., STOCKTON, CA R E C" Telephone (209) 466-6781 D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J U L 0 6 1990 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor%R)1,A`1lTS/Wyl� $Iication is k 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 f Local Health District.-k Job Address Qd0 Ilk City Lot Size PM t I Owner's Name Address-Z2 --� Cc- , a7 fa Phone Contractorr Address [) OLicense No. � Phone�.r-+ 1 TYPE OF WELL/PUMP: NEW WELL ❑ `---'-WELL REPLACEMENT ❑ DESTRUCTION ❑ " PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 41 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications IP Cl Public 1-1 Other I Cl Delta Depth of Grout Seal Type of Grout i I Irrigation Il —.-Approx. Depth € I Eastern jSurface Seal Installed by Repair Work Done ❑ Type of Pump ,� H.P,1�� State Work Done Well Destruction D Well Diameter Sealing Material (top 50'1 'a C .!1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATIONa l,f REP,A_IR/ADDITION l I DESTRUCTION i I (No septic system permi77r T! available within 200 feet Installation will serve: Residence_ Commercial_+ Other " Number of living units: Number of bedrooms 4 0) Character of soil to a depth of 3 feet:, .,:,:, Water table depth SEPTIC TANK .l ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ .�.. Method of Disposal Distance to nearest: Well Foundation Property Line .VL"EACHING LINE ❑ No. & Length of lines Total length%size's---— FILTER BED 11 ❑ Distance to nearest: Well Foundation Property Line . SEEPAGE PITS I 1 Depth Size Number SUMPS L7 Distance to nearest: Well DISPOSAL•PONDS Foundation Property Line.—.❑ 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 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."Contractor's hiring or sub-contracting signature certifies the following: 1 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 applica al for all require s q pections. Complete drawing on reverse side. ..,reF i Signed X Title: r4 � ,Date: OR DE ARTMENT USE ONLY i a Application Accepted by Data ~ 0� �. ` I! Area Pit or Grout Inspection by Date Final Inspection by ,.x 1 Date 7 Additional Comments: H ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE j INFO °AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. +,EH 13.24 1REV.1 l R sf EH 14-28