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h APPLICATION FOR PERMIT mECEIVED i SAN JOAQUIN LOCAL HEALTH DISTRICT k ,F 1601 E. HAZE T ON AVE., STOCKTON, CA AUG 2 2 1990 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) 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. / Ir Job Address /, 7 /`Y�/iL CityLot Size PM Owner's Name �a >✓ Address !Ilc� {� / fir��11 jI rJ� Phone u Contractor Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑T WELL REPLACEMENT n DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l Domestic/Private © Gravel Pack 11 Tracy Type of Casing rf Specifications 1'1 Public ❑ Other F1 Delta Depth of Grout Seal #' Type of Grout A Irrigation I I Irri I g' _�_ pprox. Depth�- i I Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well!Diameter Sealing Material {top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION f-1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is ;11 —— —- – _--�---- -- —available-within-200-feet.) j Installation will serve: Residence_____ Commercial_ Other ` Number of living units: Number of bedrooms'/-_-/ 1 i Character of soil to a depth of 3 feet: # t ` ` 4 Water table depth '7 SEPTIC TANK ElType/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ` Well r Foundation'- Property Line LEACHING LINE ❑ No. &.169 of lines I Total length/size y. t... FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth f Size Number t SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 03trict. 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 follo : "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 Cali orni .' 11 f ' 7 The applic m call for all requir inspections. mplete drawing o rev rs side. I Signed X � Title: Ma Q 4& Date: FOR DEPARTMENT-USE-ONLY Application Accepted by Date 99f Area Pit or Grout Inspection by Date Final Inspection'hy-�2 Date b A Additional Comments: 0 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. r.EH 13-24 IREV.vn5) EH 14-26 �1� l �. 2 .:Z, n