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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T YEAR FROM DATE ISSUED 1> (Complete in Triplicate) OCT Li 1989 Application is-hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This 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 the San Joaquin Local Health District. ENVIRONMENTAL HEALTH 6fal9� �-- PERMIT/SERVICES Job Address r City Lot Size PM e Owner's Name Address ��. /> > 7 '7 Phone Contractor 96U.a.4 Address License No.y 1�0� ( 6 Phone 053 TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ a PUMP INSTALLATION [!!r' SYSTEM REPAIR ❑ 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 ❑❑� Industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing be<rnestic/Private ❑ Gravel'Pack ®'Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Dept ( 1 Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump , H.P. State Work Don Well Destruction .0 . Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 FILTER BED ❑ Distance-to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Numbef SUMPS ❑ Distance to nearest: Well Foundation 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-ordinanc_es, stateiawTs_,-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 applicant must call or all required inspections. Complete drawing on reverse side. Signed X Title: Dateae� � R DEPARTMENT USE ONLY f/ Application Accepted by Date Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Perttlit/Service's 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CASH r �f + EH 13.241REV.i/nsf 3` S`Ov �S ` 0`13�� Fr grq EH 14-2e'