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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE TON AVE:; STOCKTON, CA TED Telephohe (209) 466-6781 APR PERMIT EXPIRES 1-YEAR FROM DATE ISSUED 0 3 1991 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Jo.aquin Local Health District for a permit to construct and/or install the work hereiN6Nd1/;;UX91 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 A( City Lot Size PM sip/1, Owner's Name lL Address Phone ;FW— C o n t r a c t o Add,,,, 4/1' License No.� 7 5 Phone-'I� 22.�l ill TYPE OF WELL/PUMP:" NEW'WELL WELL REPLACEMENT 171 DESTRUCTION 0 PUMP INSTA L LAT ON 0 SYSTE7REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,�5� DISPOSAL FILD. PROP. LINE .72 FOUNDATION i� AGRICULTURE WELL 41a� OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom El Manteca Dia. of Well Excavati n Dia, of Well Casing '*bvOomestic/Private W-4ravel Pack © Tracy Type of Casing— Specifications M Public H Othe1,50 r 171 Delta Depth of Grout Seal qa f Grout I I Irrigation ;�WAPPFOX. Depth I I Eastern Surface Seal Installed byz&V0/_tJ"--o, JIT Repair Work Done E Type of Pump H.P. State Work Done Well Destruction 11 Well Diameter Sealing Material (top 501 Depth—1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I. I INo septic system permitted if public sewer is U� available within 200 feet.i 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 E Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance tolnearest: Well Foundation Property Line LEACHING LINE - 171 No. & Length of lines Total length/size FILTER BED 0 Distance to'nearest: Well Foundation— Property Line SEEPAGE PITS I I Depth I Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify-that i-have,ptepared this application-and that-the work will be done in-accordance with San-dloaqoin-counly-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." The applicaynt "st call for all required inspections. Complete drawing on reverse side. Signed X Title: o ,,ttk-, Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Area Ir Pit o<P)n spection by_ Date Final Inspection by Date Additional Comments: 11 Stk 466-6781 El Led", 369-3621 0 Manteca 823-7104 0 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 (CO-rH RECEIVED BY DATE PERMIT'NO. ] INFO ASH I I EH 13-24(REV.I/R5)fvlo hit EH 14-26