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I APPLICATION FOR PERMIT 0K*"tE C E I V 0EA 0 : . SAN JOAQUlN LOCAL HEALTH DISTRICT I( 1601 E. HAZELTON AVE., STOCKTON, CA NOV 8 1989 Telephone (209) 466-6781 PERMIT EXPINVIRONMENTAL HEALTH RES 1-YEAR FROM DATE ISSUED . . (Complete in Triplicate) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District- (� I � City n�- � Lot Size PM � Job Address d ! �r ' r 7+ 43 SD . L Phone 1 Address Owner's Name Z3 7 �,��^_•,p� - f Address gS:JD License No. - Phon Contractoreg" f"s TYPE OF ELL/PUMP: NEW WELL F1 L' WELREPLACEMENT ❑ DESTRUCTION L-) PUMP INSTALLATION C SYSTEM REPAIR C3 OTHER El SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing ❑ Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation Specifications Type of Casing hdDomestic/Private ❑ Gravel Pack ❑ Tracy "'Depth of Grout Seal Type of Grout --- n Public Ci Other Fl Delta E p I Irrigation —__Approx. Depth I I Eastern �f/Surface Seal Installed by State Work Done ❑ Type of Pump H:,P.' Repair Work Done ! Well Destruction ❑ Well Diameter 'Sealing Material flop 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system m Permitted if public sewer isT T installation will Terve: Residence_ Commercial Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity t Method of Disposal PKG. TREATMENT PLT. ❑ -"- -- Distance to nearest: Well ' Foundation Property Line:— LEACHING ine LEACHING LINE ❑ No. & Length of lines ,- -.� Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation` Property Line SEEPAGE PITS .1 1 Depth Size+ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 td 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 ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in such manner as to become subj 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 mus Il for all Q ired inspections. Complete drawing.,on reverse side. Title: Date: . Signed X v � AR DEPARTMENT USE ONLY / i} Date _Area Application Accepted by Pit or Grout inspection by Date Final Inspection by ate 4 Additional Comments: C3 Stk 466-6781 El 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 F FEECK RECEIVED BY DATE PERMIT'NO. AMOUNT DUEEAMOUNT REMITTED CASH ' INFO 11 �j ..EH 13-24(REV.r/H 51 - F- EH14-26 _ _-