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APPLICATION FOR PERMIT ,A� AQUIN LOCAL HEALTH DISTRICT 1 AWE" N AVE., STOCKTON, CA��} � e (209) 466-6781 Q 1U11T EXPIRES 1-YEAR FROM DATE ISSUED NOV 0 7 1990 s (Complete in Triplicate) ENVIRONM App on is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dPRINVk ,T"s made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regu anon aquin Local Health District. �/� r Job Address 570 AZ �"r�ev STr- City N#V77.`6* Lot Size /` PM lb Owner's Name !/�Z{ DIF �fffi.! iiS Address Q 0 �l�"IJ{V 3� Pod' Cantractodress 695P,5 gwxaealicense No. Phon'e's TYPE OF WELL/PUMP: NEW WELL WELL REPLA ❑ DESTRUCTION ❑ PUMP INSTALLATION Elh�E SYSTEM REPAIR ❑ OTR r DISTANCE TO NEAREST: SEPTIC TANK�I 1®00 r SEWER LINES "} 6'C7 DISPOSAL FLD. AJ PROP. LINE FOUNDATION fi a AGRICULTURE WELL OTHER WELL PITS/SUMPS _M4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /! ❑ Industrial ❑ Open Bottom Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack /❑`Tracy Type of Casing eve- Specifications �r 1`1 Public 170Ag7,v ❑ Delta Depth of Grout Seal Type of Grout��. I t Irrigation //`rr''A�rpprox. Depth l I Eastern Surface Seal Installed by r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRJADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence T Commercial_ Other . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth e SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size �"Cr FILTER BED ❑ Distance to nearest: Welloundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS Cl Distance to nearest: Well Founuation 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 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 10 workman's compensa- tion laws of California." The applic t st call f all req 'ed inspections. Complete drawing on rev se side. Signed X Date /7 FO DEPAR ENT U ONLY Application Acce tad 1 I� J v PP F , p5.*� F 1113 11TO Date Area Pit or Grout Inspectipn by Date Final Inspection by ��' �t�'��7 Date Additional Comments: W ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Bax 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT /REMITTED CK CAST/1-� RECEIVED BY DATpEr PERMIT'NO. + EH13.241REV.liH51 '4 r� c �'1 QJ Ip1 EH 14-26 UUJ 1 t l V i