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APPLICATION FOR PERMIT 'ECEIVE "' SAN JOAQUIN LOCAL HEALTH DISTRICT K U 1601 E. HAZELTON AVE., STOCKTON, CA OCT 2 3. 1989 I Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES TYEAR FROM DATE ISSUEDPERM IT/SRVIC5 (Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applicatioh-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. J i �o A: Job Address City Lot Size PM �fkQ ,r j G Owner's Name dress Y090 althL Phone-Sy6- yz-,s6f Confracltrr- S Address License No.7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,� 4 PUMP INSTALLATION �"�� p� YSTEM REPAIR ❑ OTHER 0 ,\] I DISTANCE TO NEAREST: SEPTIC TANK SEWE#i LIN DISPOSAL FLD. PROP, LINE �1 FOUNDATION AGRICULTURE WELL- OTHER WELL. ., PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 Public F1 Other 17 Delta Depth of Grout Seal Type of Grout _. E I IrrigationApprox. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump '�(1�—H�P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') *� ' Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIRlADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is O available within 200 feet.] C 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. ❑ +t. Method of Disposal Distance to nearest: Well Foundation Property Line l I 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 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 Wth San Joaquin ddunty ordinances; state laws, and i rules and regulations of the San Joaquin Local Health Di$trict. Home owner or licensed agent's signature certifies the followingi 'I certify that'in'!he 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 app cant ust call fo all re u' c'ons. Complete drawing on arse side. Signed X Title: Date: FOR PARTMENT USE ONLY Application cepted by Date /� Area Pit or Grout Inspection by Date Final Inspection by > J Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 4f INFO AMOUNT DUE AMOUNT REMITTED CASFf RECEIVED BY DATE PERMIT'NO. +.EH 14-28 rREV.,i x s,EH -28 36J_V p G(,� f�,z� p,��2 /e i