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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �� 1601 E. HAZE T ON AVE., STOCKTON, CA ED Telephone (209) 466-6781 DEC 6 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSVSR R NNIENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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. OqS214 10 Job Address ` 303 AI 41101�e2 x5j. City Lot Size — PM //�n ' to Owner's NameZ� Address L , Phone _.2Q •• G i Contractor s` ox 19 6 z7 License No.1 G V� 7J2 Phone_ V S TYPE OF /PUMP: NEW WELI ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 00 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Indus ial El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Zomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _-Approx. Depth I I E stern Surfac al Installed by Repair Work Work Done P-1*`Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing Material (top 501 J) Depth Filler Material (Below 501 -- Q TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is W available within 200 feet.) 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 ❑ 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 Number —4 SUMPS Ll 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 ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. Home owner or It ed 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 rson in su manner as t becomes ject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies a following:"I c rtify that i perfo a ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion la s of Califon 'a." The pplicant must al all r mp ete rawingo r side. / q Sign d X Title: � Date: ` FW6EPARTMENT USE ONLY t '7 Application Accepted by Date / Area v� Pit or Grout Inspection by Date Final Inspection by Gz1 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK RECEIVED BY DATE PERMIT'NO, INFO CASH a.EH 13-24(REV.t x 5) `16G�{ EH 14-28 1