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r r1f r �f h I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; � d +s !� 1601 E. HAZEL T ON AVE., STOCKTON, CA �j Telephone (208) 466-6781 JUN 1 3 11991 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH , ' (Complete in Triplicate) PERMIT/SERVICES f 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. pp Job Address I ~ Cit�tla Lot Size PM Owner's Name IISP�J-N A G Al© Address 3 OU 3:71 Al RLT Phone �A) Contractor I E JR 4C Address MY G SSC l#y �� License No.o�'`! ! `� Phone ala 313 R TYPE OF WEL /P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 'y 'AGRICUCTURE WELL OTHER WELL PITS/SUMPS zw INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"1 Public i! [1 Other Cl Delta Depth of Grout Seal Type of Grout G(Irrigation �I' _-Approx. Depth �I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump A JPZU H.P. & State Work Donr;�lV�'r/ u�'8f A:- Well :Well Destruction ❑ Well Diameter Sealing Material (top 501 d! Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f l REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is 4 i available within 200 feet.) Installation wiill serve: Residence_1 Commercial Other 111 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 t PKG. TREATMENT PLT. ❑ Method of Disposal s Distance to nearest: Well Foundation Property.Line 3 I .i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Ij SEEPAGE PITS, I I Depth I Size Number s i SUMPS li ❑ 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 L_ocal Health Di§trict. i 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 parson 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." f The applicant must call for all required inspections. Complete drawing o versa a. Jp ,t Signed X {� Title. Date: f}. FOR DEPARTMENT USE ONLY 6- -1 Application Accepted by 41-0/1 Date Area Pit or Grout Inspection by ate Final Inspection by Date J 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. Hazeiton Ave., P-O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY, DATE PERMIT NO. +.EH13-24{DEV.t i H s1 1010 ly Tov EH 14-2A I