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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DEC 2 7 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpumAbMR0f*A"TA1l MQW,1dio&WS$Wan Joaquin Local Health 'D�ist�ricct. Job Address 1-Tilt �y� City Lot Size PM Owner's Name Address Phone Contfactor i- lar dC1wT9._Aw -tJZ Address'!7� '4rS,Sr=jQ%1j0(.A�icense No. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public F] Other {l Delta Depth of Grout Seal Type of Grout I I Irrigation --.-Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is S available within 200 feet.) Installation will serve: Residence X_ Commercial— Other y Number of living units: Number of bedrooms--3 V 1 Character of soil to a depth of 3 feet: A_µ0__ Water table depth SEPTIC TANK $, Type/Mfg Capacity 6AL. No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation G.-._.,. __.._ Property Line LEACHING LINE No. & Length of lines _+7 Y, 1 Total length/size FILTER: BED= ❑ Distance to_nearest_ Well Foundation �r _ Property Line _ I SEEPAGE PITS [ I Depth Size Number SUMPS L-) 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, ands% 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, 1 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 certifiers the following: "I certify that in the performance of the work for which rs per 't is issued, I shall employ per ns subject to workman's compensa- tion laws of California.�`t, –�rd �- � s - The applic must ca for al req re I spections. Complete drawing on reverse side. �� Signed X ^ AA LaLA Title: _ tib-s�4Ji_� Date: y� FO DEPARTMENT USE ONLY r Application Accepted by Date rea Pit or Grout Inspection by Date �Inspection by Date Additional Comments: Y f ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca -7104 ❑ Tracy 835-6385 ep. ♦� �f .t(ji��-�^� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 201 Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIY NO. INFO Cwsrw C3 o O d + EH 13-24;F1 Ev.11 n5) C>,C) EH 11-26