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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT JAN 10 1989 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 ENVIRONVIE€vTAL I-IEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is he+eby 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 welUpump and the Rules and Regulations of the San Joaquin Local Health District. y/ /� Job Address 761,7 �r!� �,.�YLJ City Lot Size PM Owner's Name LAE_ Y 11ZM A Address Phone Contractor Address v2 1 License No.,4e 7M Phone_ z� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION gE GJI-C)SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST-: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRTC LTURE WELL OTHER WELL PITS/SUMPS- INTENDED ITS/SUMPS INTENDED USE TYPEE-OF-WELL PROBLE AREA CONSTRUCTION_SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑-Mahte`ca Dia. of Well Excavati lon Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing € Specifications 1-1 Public 171 Otiher ❑ Delta Depth of Grout Seal' t Type of Grout _ MIrrigation __Approx.:Depth I 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H' .P. f5 t StatelWork Done _ f Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION l 1 DESTRUCTION i I (No septic system permitted it public sewer is II available within 200 feet.) 6 f It Installation will serve: Residence_I Commercial_____ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 3 I Water table depth SEPTIC TANK ❑ Type/Mfg! Capacity ! No. Compartments PKG. TREATMENT PLT. ❑ i j Method of Disposal Distance to nearest: Well Foundation ! Property Line 1 ; Fr LEACHING LINE ❑ No. & Length of lines -_,. f1 Total length/size FILTER BED El Distance to nearest: Well ? Foundation i Property Line SEEPAGE PITS l I DLpth I Size a E 'Numb)► 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 Jvith San Joaquin county ordinances, state laws, and rules and regulations of the San'Joaquin Local Health District. i I Home owner or licensed agant'sfsignature 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(tiring 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." { i The applicantr requ ctions. Complete drawing on revs a side. t l I Signed X Title: Date: V?JR DEPARTROTNT USE O LY Application Accepted by ' Date i Area Pit or Grout Inspection by D e Final Inspection bDate Additional Comments: .❑-Stk-466-678��--C�-L-od'r`- acn—�-�-------•-C3-Mentsea--$2i'3--741F14�•--�--{3�raCy--'$35��85--�-r---,^•-^_��^- - --�.._.. r...- --- .�,..�'r Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMDUNT'REMITT.ED CASH RECEIVED BY DATE PERMIT NO. +.EH 13-24 01 Ev,v n 5) EH 14-25