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APPLICATION FOR PERMIT i/s,179' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA RE �E IV� Telephone (209) 466-6781 D% PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 6 1989 {Complete in Triplicate} ENVtR&W.40TALWWaTWicationApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install 0 is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and thcTVE6@ ,0E&e San Joaquin Local Health District. ,1,4,r__ Job Address $ w+ Y _ City Lott Size PM Owner's Name �t Address 74 �l s7 L�?_. Wld,�R..V4, , .a�tT�`!+� Phone Contractor!u — Addres6 V� Z 4L4- License NO)6 )-3 73 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 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 Lr?Domestic I Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications F] Public Cl Other Cl Delta Depth of Grout Seal Type of Grout ---- I I Irrigation —_Approx. Depth t I Eastern Surface Seal Installed by _ r Repair Work Done E.�' Type of Pump 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 )` REPAIR/ADDITION I ] DLSTRUCTION l I (No septic system permitted if public sewer is 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 r 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 t 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 with San Joaquin county ordinances, state laws, 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 call for all re ired inspections. Complete rydrawing on reverse side. � Signed X_ _ 1"�Titie: 1L1 Date: f f I e / — FOR DEPARTMENT USE ONLY Application Accepted by Dat Area u Pit or Grout Inspection by Date 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 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. a EH53-24 IREV.1/0 51 1 �.�y EH 14-26 D-`I]