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4 x APPLICATION FOR PERMIT PAYMEN i SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 JUN 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VIRONMENTAL HEALTH °C1MITWPVICE'Z 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. Job Address C ''f /rD�/� City /J Lot Size % �E'� PM Owner's Name ci 1h d T Sto<� n Address �"" �i ' �A Phone C-0ii- Contractor �"`' ��/, Address 9126 License No.3,19 3�5 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �I PUMP INSTALLATION 0 SYSTEM RREP.51R ElOT ER C-/��'/i DISTANCE TO NEAREST: SEPTIC TANK _/ SEWER LINES J5 DISPOSAL FLD. PROP. LINE FOUNDATION _� AGRICULTURE WELL OTHER WELL �� i !PITS/SUMPST, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / ❑ Industrial ❑ 0 en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 02 ❑ Domestic/Private el Pack ❑ Tracy Type of Casing p✓�% Specifications ['I Public Ll Other F] Delta Depth of Grout Seal �� Type of GroutC�'1 I 1 Irrigation _50t.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 ✓/lip�/fdf Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 Property Line a SEEPAGE PITS I I Depth _Size Number 0- SUMPS SUMPS Ll 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 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: "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 must IIJor 0 required inspections. Complete drawing on reverse side. Signed X ��` �c�y Title: o Fc �Z� /� Date: F E T USE ONLY t Application Accepted by Date Area Pit or Grout Inspection by Date G �� Final Inspection by Date 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE ` PERMIT'NO. + EH 13.24(REV.I/M 5) 3 S �� ?J�s vky-7 ) EH 14-2e