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_ 1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E:_f1AZELTONI.AVESTOCKTOIV, CA Telephone (269)"466-6781"' nE C F I VE' D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 6 1989 (Complete in Triplicate) C�vg (� ! L �t Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or nst8lf 199,�1h>'tjeiTAL. 64hrst�pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or Na. 1862 for well/pump and �rd 'trf the San Joaquin Local Health District. f Job Address ! City Lot Size PM eJD Ow s Name Address31) Phone Contrac Address ® License No.L&U—B Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ( � OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRTCULTLlRE WEt'L 1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEIyI AREA'� CONSTRUICTION SPECIFICATIONS 171Industrial ❑ Open Bottom ❑ Manteca . f -Dia..'of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 1 Type of Casing Specifications vl blic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation /__ Approx. Depth I F/,stern Surface I Inst fled by - 1 Repair Work Done a Type of Puml: ' H•P- State Work Done a T Well Destruction ❑ Weil Diameter Sealing Material Itop 501 Depth ' Filler Material (Below 50'1 -- TYPE OF SEPTIC WORK: NEW INSTALLATI6K 11 RFPAIR/ADDITION f I DESTRUCTION ( I (No septic system permitted if public sewer is available within 200 feet_1 Installation will serve: Residence, Commercial :' Other ` Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: C< Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f Foundation, Property Line SEEPAGE PITS I I Depth Size 7 � E '� Number r SUMPS 0 Distance to nearest: WellFoundation{ �l Property.Li Ei'- DISPOSAL PONDS ❑ hereby certify Shat ve prepa this application and that the work will be done in accordance with San�Joaquin county ordinances, state laws, and rukes and regulaC sof the San Je q.in Local Health District. �,j, i permit is issued I shall not ant's si tore certifies the following: "I certify that`in the performance of the work for which this p , Home owner licensed agent's g g Y b employ any erson insuch manner s to become subject orkman's compensaLon�aws 6f,.California." Contractor's hiring or sub-contracting signature certifies t following: ''I ertify t in t e pe o an f- a work for which this per itis issued, I shall employ persons subject to workman's compensa- tion law of California." The a licant must ca requd i ompl ~deaw!ng on rev e. Signe X Title: \``-. � � Date: �71 �jIt f FOR DEPARTMENT USE ONLY Application Accepted by Date,/ Area J �] Pit or Grout Inspection by �' A1' �' Date Final Inspecti n-by L~ Date / Additional Comments: I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 1P,ERMIVNO. + EH13-24(REV.I/Hs) I EH 14-28