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APPLICATION FOR PERMIT PAYMENT ~- SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZETON AVE., STQCKTON, CA RECEIVE® Telephone (209) 466-6781 JUN 0 6 1990 PERMIT EXPIRES 1 YEAR FROM DATE ISSUM JOAQUIN COUNTY (Complete in Triplicate) PUBDC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION 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 welUpump and the Rules and Regulations of the San Joaquin ` Local Health District. / p I 3YO0 K 1 i,, 011 }�{� h6G�t� L Size ' PM Job Address 1�City at �eYS U V\/I Address 31/00 f� h r9 Phone -/79'-.7-3S3 I Owner's Name�Q�� -- , Contractor PUC.k ` d w4g,ss S el,1r LS?v -J1c�c oLf � Cicen�s�e No. 1b0 Phone qTZ(`-59Z? ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ """'�"'"` - """ � _ -PUMP INSTALiA710N�❑ »�ter---SYSTEM-REPAIR �i' �+ .. ,_.,_.., __s ._ OTHER,❑ � - ,...._ �. �;'"� DISTANCETO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �� Y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing le Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications y [I Public f_1 Other ❑ Delta Depth of Grout Seal Type of Grout _ r I I Irrigation _.Approx' De th-r_t I Eastern Surface Seal Installed by G Repair Work Done )t Type of Pump er H.P. State Work Done epoo f k).' a♦ umf/ W Well Destruction ❑ Well Diameter +< rf Sealing Material (top 501 f G Depth o Filler Material (Below 501 _ V TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _ Number of living units: Number,of bedrooms ' S 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 I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line u - A SEEPAGE PJTS+�+.. a I+rBepthti .. �s5ue-_.. _ - _ Number< - :. w SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f sI 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." 4 The applicant t call for all re ired ' spections. Complete drawing on reverse side. C� r Signed X Title: e Data: 1 " — FO DEPARTMENT USE ONLY Application Accepted by Date Area 117!,_-� Pit or Grout Inspection by Date a Final Inspection by23`r<1_�1 Date Additional Comments 1 i 11t>.� + Z- t�` ,,ten*c_ cJ� Se QJz c A-- ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 h� , Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P,O. Box 2009, Stk., CA 95201 a' FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT'NO. ^ho +, ,EH 13.24(REV.i/n51 Eio r (f k EH 14-26 ��O -T f