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~ x APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT, 1601 E. HAZEL T ON,AVE`., STOCKTON, CA 77CEIVED Telephone {209} 466-6781 k PERMIT EXPIRES 'I'YEAR FROM DATE ISSUEDDEC 6 1989 {Complete in Triplicate} ENVIE;UNMENTAL1/HEA�+LTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instaIFi9-0iWh4&E t 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 _ro_/�,J4SE— Job Address City Lot Size PM Owner's Nam B I;� qs3 one Contractor dress 01SOX 152, License No. �6 Z,3 73 Phone 466—,F(a Z TYPE OF /PUMP: NEW NELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i`i�Public n F1 Other C-1 Delta Depth of Grout Seal Type of Grout _ Ih'Irrigation Approx. Depth I I Eastern S i ce Seal Installed by Repair Work!!Done r—TYpe of Pump _-,_. l!TH,P. State Work'Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below,50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION zl I I (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. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tines_. Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS E I Depth Size Number SUMPS Cl 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 San Joaquin Local Health District. Home owner or I used age 's signature certifies th following: "I certify that in the performance of the work for which this permit is issued, i shall not employ any on in such 49ner as to become j ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the flowing: "I c that in e o a e of the r which this permit is issued, I shall employ persons subject to workman's compensa- tion laws Califo nia." The appli ant c I r all r q o plete drawing on side. Signed Title: Date: �+ �� /FOR DEPARTMENT USE ONLY � Application Accepted by /Y 2 r �lGpate Area 1 Pit or Grout Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. INFO CASH + EH 1 -24(REV.I/a5) 4 EH 144-29