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APPLICATION FOR PERMIT I l E i`� SAN JOAQUIN LOCAL HEALTH DISTRICT E C;`E 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 J U L 0 6 1990 PERMIT EXPIRES 1'YEAR FROM DATE ISSUE NVIRONMENTAL HEALTH i (Complete in Triplicate) PERMIT/SERVICES 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 �.✓�-/` City Lot Size PM Owner's Name _ 4 K oast J�e�l.ess Phone Contractor AddressAQ 4 &44D'40 icense N > Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR .A_ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca _pia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing''— _ Specifications I`I Public ❑ Other ❑ Delta Depth of Grout Seal 'c 'Type of-Grout. _ I I Irrigation —.Approx. Depth I I Eastern Arface Seal Installed by Repair Work Done (Type of Pump H.P. � State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material (top 50'1 Depth ' Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION f'I REPAIR/ADDITION i I DESTRUCTION 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 x� I SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments ` P_.KG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest:, Well Foundation Property Line LEACHING LINE ❑ No. & Length of,lines Total length/size - ! FILTER BED ❑ Distance tc nearest.'' Well * Foundation Property Line SEEPAGE PITS l I Depth Size f'0,,_ � Number SUMPS L7 Distance to nearest: Well Foundation Property Line (� DISPOSAL PONDS LD l 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, ander rules and regulations of the San Joaquin Local Health District. f Home owner or licensed agent's signature certifies the following:"'1 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." 3 The applicant m lit r all required ctions. Complete drawing on re rsa side. Signed X Title: Date: � F, R DEPARTMENT USE ONLY Application Accepted by Date Area Q Pit or Grout Inspection by Date .r 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. Hazelt6n-Ave., P.0..Box 2009, Stk., CA 95201 - h t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIVNO. +.EH 13-24{REV.1 i a 51 EH 14-26 `I.. "rl/ 9 O 19 0-1 t