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.. APPLICATION FOR PERMIT ` SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE® Telephone (209) 466-6781 MAY 0 2 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY IComplete in Triplicate) PUBLIC NHEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or insti3'tF {�fi€VGNIt`�� &ffA10.WYAI�1 cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. D r Job Address 4131J !w-r�/c- �U� City S3 a '�`� Lot Size PM Owner's Name z 1/ (70• Address `.�• SCJ �'z3 6-t?'�cox-d Phone f ContractorjQVIlleZIA141A,11142 re Address License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES _ 76Jd DISPOSAL FLD. PROP. LINE Aff FOUNDATION AGRICULTURE WELL V4 OTHER WELL 0PITS/SUMPS .( ¢ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �Jy/ ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation l0 Dia. of Well Casing 7 El Domestic/Private ❑ Gravel Pack El /dTracy Type of Casing �tc Specifications 1'1 Public _64_6 � Other Cl Delta Depth of Grout Seal '"3df Type of Grout !,I Irrigation ---Approx. Depth 4 Eastern Surface Seal Installed by 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 (1 REPAIR/ADDITION l I DESTRUCTION 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 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 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 with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. 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 mu call for all quired ins ctions. Complete drawing on reverse side. I Signed X Title: Date: �� d FOR DEPARTMENT USE ONLY 11 Application Accepted by Date v Area Pit or Grout Inspection by Date Final Inspection by ` Date J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63$5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUN`T,[DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY y+DARTE /P�ERMIT'NO. rEH13-241REV.k/x51il / y � �� x� /Jl \ /�� J� _;�7 EH 14-2e