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A . E] .ter F ' APPLICATION FOR PERMIT RUE V ED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA J U L 15 1991 O �� Telephone (209) 466-6781 ENVIRONMENTAL HEALTH 3 �3 PERMIT EXPIRES TYEAR FROM DATE ISSUED PERMIT/SERVICES ,-t r:5- L (Complete in Triplicate) Application is hereby mA�othe n Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliant n County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address a k W s City Lot Size PM Owner's Name V411 . l��r�-- Address Phone J �/J� p p P Y /� p f Contractor m4rt ` M �'&PAI ress � l eel- /��_�License No. � � Phone '6 TYPE OF WELL/PUMP: NEW WELL, WELL REPLACEMENT F-1DESTRUCTIONIDPUMP INSTALLA;fIQNY µ SXSTEIVI_REPAIR ❑ OTFIER.I� 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 t �f ❑ Industrial ❑ Open Bottom E)•Manteca Dia. of Well Excavation Dia. of Well Casing (( Domestic/Private OkGravel Pack 0 Tracy Type of Casing Specifications t i"I Public [_1 Other Cl Delta ` Depth of Grout Seal � _. r�?l?� Type of Grout 1 1 Irrigation _.-Approx. Depth l 1 Eastern �Surface Seal Installed by - I Repair Work Done 1010 Type of Pump ejlj H.P. ,7 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 50'l 5 Depth Filler Material (Below-509 -- TYPE OF SEPTIC WORK: NEW INSTALLATION 1,1 REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feeLi 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 I PKG. TREATMENT PLT. ❑ 5 iy Method of Disposal s -'Distance to nearest: Well Foundation Property Line LEACHING LINE ❑' -No. & Length of lines Total length/size- All FILTER BED ❑ Distance to nearest: Well Foundation °Property Line I SEEPAGE PITS i I Depth Size Number it "�SUMPS""" "° _Ll"rDstance-to nEfarest: -Well '""""`""'^"Foundation"""' Prope-fty Cines � DISPOSAL PONDS ❑ 4 w # 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 District. a 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 certif)�that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calif The applicant As call for all re uire spectio omplete drawing n reverse side. I Signed ko Date: + FO DEPARTMENT USE ONLY Application Accepted by Datey� Area 17 Pit or Grout Inspection Date Final Inspection by Date l Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ liacy 8355--6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CAS H ♦.EH13.24 1REV. 51 '�~ �` 5� EH 1428 r •_ r