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• 0 APPLICATION FOR PERMIT 10 SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVE[? Telephone (209) 466-6781 MAR 2 0 1991 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SANJOAQUINC PUBLIC HEALTH SEOUNry ' (Complete in Triplicate) ENVIRONMENTAL HFF' kkRtV1Cl�E,..3' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descr%TgM%W00Nlion 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 510 F /4(26n d /Ick _ CitySToakmn Lot Size /r2 S acres PM Owner's Name .STOC,kT?ft (/e V. C`r)2 Address SIO E / la&N.O ha, Phone 7 YR' 741/ 72 Contractor. 5P eIYs_" Address License No.,S�9 Phone Y65 IA712 TYPE OFLLVr _ /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE I NEAREST: SEPTIC TANK >_82--ft— ,I M; SEWER LINES 100 -Fr DISPOSAL FLD.71011 PROP. LINE Of SM FOUNDATION 82 -ft AGRICULTURE WELL �� OTHER WELL? MI PITS/SUMPS I M 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 11 Public ❑ Other n Delta Depth of Grout Seal Type of Grout_ _ I I Irrigation __Approx. Depth 1 I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Seating Material (top 50') 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 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 PLL Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 13 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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 applican sAI call) for all requuiiAredininspeecctioorrls.. Completedrawingon reverse side. Signed X Title: CO2ASW Date: Afaltl FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I 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 NFO AMOUNT DUE AMOO�UNNTT REMITTED CASH RECEIV//EBY DATE "Ef1Mr-jo. fEH 13NIREy.r/x51 7� Z / X17 qP EH VIM Cl Cl OJ�f",,