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APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., AUG 17 1990 STOCKTON, CA � Telephone {2091 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City of Size PM I 1 Owner's NameT. V1_ Address _ Phone r r x_31 se 96� Phone -0 ice se Contractor ddress No.. TYPE OF WELL/PUMP: NEW WELL- ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 119— SYSTEM REPAIR 9 \ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE —� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ry TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - Bomestic/Private ❑ Gravel Pack ClTracy Type of Casing Specifications f'1 Public F) Other ❑ Delta Y Depth of Grout Seat Type of Grout _ I i Irrigation --Approx. Depth i I Eastern t, � 1 Surface Seal Installed by � - Repair Work Done Type of Pump .4=1I 1 L:: H.P. — State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material Welow 501 — r TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION t ! _DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.t Installation will serve: Residence Commercial'_ 'Other _ f W 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 d ! LEACHING LINE ❑ No. & Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth--Size T -L__--Number I " — SUMPS L-1 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 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 mu t c II for all required inspections. Complete drawing �oon}reverse side. Signed X `r V D-I �� Titled i_O�� _ Date: FOR DEPARTMENT USE ONLY �f( Application Accepted by Date r/ Area ;214 Pit or Grout Inspection by Date Final Inspection by Date �.3/ Additional Comments: k ❑ 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 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY [)ATE PERMIT NO- Cr INFO +.EH 13-24 MEV.I/11 5) —49 EH 14-28