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APPL CATION FOR PERMIT �J • JOAQUIIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 12091 466-6781 DEC 6 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFNVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2040 W. Washi ngtnn street City St nrrk+nn Lot Size PM Owner's Name rra1—Far-M�C$ppl Address Phone Contractor um Address 2825 E. My -1rt a License No. 91 996A Phone TYPE OF WELL/PUMP: NEW WELL LX WELL REPLACEMENT ❑ OE$TRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Pr`W 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 Cl Manteca Dia: of Well Excavation 8 1 n e Dia. of Well Casing 2 in Che ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCH 40 PVC n r Specifications 1'I Public ❑ Other ❑ Delta Depth of Grout Seal 1.0 ft Type of Groutramptj tthpirit on I I Irrigation 25- Approx. Depth I I Eastern Surface Seal Installed by grnut pump ' Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 201 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. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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." Contractors 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." Theapplic m t call for all requir it cions. Complete drawing on reverse side. �7 p Signed X Title: ,Y� Date: 1 —/ —o7 /O/JR, TMENT USE ONLY Application Accepted by , �✓"''.� Date /l J 07 Area 7 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Cl 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EHt4Nl c> -. lflEy.vx51 13Q� Vw � EH 1434 + 1