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3 ✓I APPLICATION FOR PERMIT S EALTH DISTRIC 601JE.. HAZENTONCAVELOAL ., STOCKT'ON, CAT RECEIVED H Telephone (209) 466-6781 OCT 2 6 1989 PERMIT EXPIRES TYEAR FROM DATE ISSUED • (Complete in Triplicate) - ENVIRONMENTAL HEALTH PERMIT/SEE y.10ES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escnbed. is app is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin Local Health�Dyistrict. f Job Address" - rJfl $1 _ City Lot Size PM Owner's Name f Address s �'�'�` Phone Contractoiu!;��P_ Egg_;( Address f6 64,PL ��-- License No. 6_)-- PhonA ? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ T 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" Dia. of Well Excavation Dia. of Well Casing VDomestic/Private ❑ Gravel Pack} ID(Tracy +.� +.� Type of Casirig Specifications I`1 Public F1Other ,,t,>lJJ Cl Delta Depth of Grout Seal Type of Grout I I Irrigation --Appr6x. Depth 1"I Eastern'* --.`"'Surface Sed Installed by Repair Work Done � Type of Pump- H-?Z� 1_ — 1-- State Work Done' M Well Destruction ❑ Well Diameter Sealing Material (top 50') r N F Depth � � Filler Material (Below 50')-- — ' TYPE OF SEPTIC WORK: NEW INSTALLATION { 1 REPAIR/ADDITION i I DESTRUCTION E 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 4•. SEPTIC TANK ❑ Type/Mfg•'t-- .' Capacity Ni No. Compartments PKG. TREATMENT PLT. ❑ "". `'�✓ Method of Disposal Distance to nearest: Well* Foundation Pr6perty Line LEACHING LINE ❑ No. & Length of lines Total aIe g/size ti f FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line r SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line y DISPOSAL PONDS ❑ j' -''��-�` -�" � - "� 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 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." i The applicant f or ail requirbd spections. Compiete drawing on averse side. _ Signed Title: I Date: LQ I, FOR DEPARTMENT USE ONLY � 41 7 Application Accepted by t Date // , Area �+ !4 Pit or Grout Inspection by Date Final Inspection by 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 F FEE AMOUNT DUE AMOUNT REMITTED` `"`CK RECEIVED BY DATE PERMIT N0. INFO .. CASH r +.EH13-24(REV.tin5Y 35 l� a7-$ - EH 1448