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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Mt;EIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA AUG 0 f 1990 Telephone (209) 466-6781 HEALTH ENVIRONMENTAL H PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES L HE5 r.t (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. " z � Job Address W-0P ` CA T-- City Lot Size PM I Owner's Name Address Phone Contracto Address _ C--¢ a License No: Z. L Phan a.W/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ,} FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ILDomestic/Private ❑ Gravel Paf k L1 Tracy Type of Casing Specifications j f l Public ❑ Other i �❑ Delta+ Depth of Grout Seal Type of Grout I I Irrigation —.-Approx. Depth { I Eastern f/ Surface Seal Installed by T Repair Work Done ❑ Type of Pump�_ H,P. _ �� State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth 1 1 Filler Material (Below 50') F TYPE OF SEPTIC WORK: NEW INSTALLATION I] �RFPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is M ' I �" available within 200 feet.) in will serve: Residence s. Commercial Dther' Number of living units: Number_of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal --�' Distance to nearest: Well Foundation Pioperiy L"ine" - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line } SEEPAGE PITS ( I Depth I Size.. ` ^}s""' Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San aquin county ordinances, state laws, and rules and regulations-of the-San Joaquin-LocahHeaith_D3trict. Home owner or licensed agent's signature certifies the followin g: "I certify that'in`the-performance of the ork 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." oniractor's hiring or sub contracting signature certifies the following: "I certify that in tfie Performance-of-the work for which this permit is issued, I shall a ploy persons subject to workman's compensa- tion laws of California." i The applicant must call for al required iKp tions. Complete drawing on reverse side. Signed X Title: Date: FQR DEPARTMENT USE ONLY Application Accepted by Date Area / Pit or Grout inspection by Date Final Inspection by Date g 46 Additional Comments: •', ❑ 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 96201 dye FEE CK �� ! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �.. ; +.EH 13-24{qEV. EH 4-26 i� GC33 r 60-12011