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APPLICATION FOR PERMIT x � - SAN JOAQUiN LOCAL HEALTH DISTRICT �rte": ��"a � '14 ;v 1801 E. HAZELiON AVE., STOCKTON, CA y� Telephone (209) 466-6781 a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JAN 27 19.89 (Complete in Triplicate) - ,7 M1._U 'i permit to construct and/or install the work hFiEOV'ydescribedyT Application is hereby made to the San Joaquin Locale Health District for a his.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 fhb San Joaquin Local Health District. r1; City Lot Size S PM Job Address `tr�nll (/! r7,,�, �CJi Yw Phone/ Owner's Name Address ��(� 1 _ Phone 69 �tt��7 ld�i�0 � .�[�License NO, Contractor U� _ ` '�Addsess TYPE OF WELLlPUMP: NEW WELL El REPLACEMENT D DESTRUCTION El PUMP INS'ALLATION ❑ SYSTEM REPAIR El 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 ing L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excaavati Dia. of Well Cas ' Type of Gasing O Specifications Domestic rival ravel Pack ❑ Tracy yP T e of Grout t D Delta Depth of Grout Seal ('1 Public f,1n tO^ther I * I I Irrigation gsa. pprox. Depth l I Eastern Surface Seal Installed by ' H.P. State Work Done Repair Work Done LJ Type of Pump -- do Well Destruction [I Weil Diameter Sealing Material Itop 50'1 Depth `AJAX. - Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 RLPAIRIADDITION l l DESTRUCTION I I (No septic i yin system emitted if public sewer is availableInstallation will serve: Residencek Commercial— Other Number.of living units: Number of bedrooms Water table depth fJ Character of soil to a depth of 3 fei et: No. Compartments SEPTIC TANK ElType/Mfg Gapacty Method of Disposal PKG. TREATMENT PLT. ❑ fil Distance to nearest:' Well Foundation Property Line ,.i 1 LEACHING LINE D No. &}Length of lines Total length/size FILTER BED ElDistance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth' Size Number i Property Line SUMPS ❑ Distance to nearest: Well Foundation ! DISPOSAL PONDS D A hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. 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 Home owner or licenuch m is sig. to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person s certifies the following: certify that s the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- in tion laws of Californi .' r f The applicant mu II for all requ' S. Complete drawing on rev a side. i Signed Title: /1/1�i S Date FOR DEPARTMENT USE ONLY �� k Date Area Application Accepted by — �7�q Dat -L -�Fl I Pit or Grout Inspection by Date ry.0-24 Final Inspection by Additional Comments: 4 I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M5 Applicant Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ff=H! MOUNT REMITTEDKRECEIVED BY DATE PERMIT'NO. EH 13-24 1 REV.ii H 51 3 EH 14-26