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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZEL T ON AVE., STOCKTON, CA APR o 1991 Telephone 12091 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete(Complete in Triplicate) 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. j Job Address City Lot Size PM Owner's Name Address --- Phone Contractor Address Z/frV, License No. Phone TYPE OF WELL/PUMP: NEW WELL,,❑-„ ` -WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION-0 "' SYSTEM REPAIR' ❑ OTHER dP,Jt�7Ph��.�LgL'ED 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=SPECiFIGATIONS- �_ ----a----- � � — ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i (� Fl Public I-1 Other f-] Delta Depth of Grout Seal Type of Grout—_ - I Irrigation — Approx. Depth I 1 Eastern_ Surface Seal Installed by V ► Repair Work Done LlType of Pump 1TV-9 ..-_ H.P. ,G _ _ _ State Work Done&_)922 EDrZD Z/ilply/y Well Destruction ❑ Well Diameter Sealing Material (top 5017pubfic Depth Filler Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION !.I REPAIR/ADDITION LI DESTRUCTION I 1 INa septic system permiavailable within 200 feetInstallation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms f 7Character of soil to a depth of 3 feet: } Water table depth SEPTIC TANK ❑ Type/Mfg Gapacity No. Compartments 4_PKC. TREATMENT PLT. ❑ Method of Disposa Distance to nearest: Well Foundation~.t Property Line LEACHING LINE D. No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ {_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 # T Trules 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 su manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foliowi I entity 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 Cali The applicant I fo II required inspections. Complete drawingrev r side. Signed X Title: _( Date: F DARTMENT USE ONLY ^��/ Application Accepted by Date 1-16 ! Area �/,3 Pit or Grout Inspection by Date Final Inspection b;. � Date�1�I"C1 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 6 CASH RECEIVED BY DATE PERMIT NO. + EH1124 IREY.t/x 51 FH 144.28