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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 i i ^PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J JUN 7 1989 �J � (Complete in Triplicate) _ Fnn ,- Application is hei eby made to the San Joaquin Local Health District for a permit to construct and/or install the work-here,,'-desGi&8'TH lapplic tion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Reg�latio'ds of.%Ifie�San Flu Local Health District.- . ///�/f J //ob Address � )Zai ^' r �G[J,�P�/�{'�(,`;�/�r cityi_aff� Lot Size PM ..r Owner's Name^ A, iI Addr6s i 1� 7" �16' Phone A Contractor n r ss r ! icense No. / Phone S-I TYPE OF WELL/PUWP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION 1-1SYSTEM REP91R ❑ O HER/❑ DISTANCE TO NEAREST_: SEPTIC,TANK •SEWER LINES :STT DISPOSAL FLO.y�-PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WEL4' PROBLEM AREA CONSTRUCTION SPECIFICATIONS, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ GraW Pack ❑ Tracy I Type of Casing ' r Specifications 1 f'7 PubJic Fl Other r fl Delta 1 Depth of Grout Seal .Tf Grout ILJ,".9.1ion ZApprox. De th I 1.Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump � ZC H.P. 2 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') $ Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I I DESTRUCTION I I (No septic system permitted if public sewer is available_within 200 feet.l _ _ Installation will serve: Residence_ Commercial_ Other Number of living units: — Number of bedrooms Character of soil to a depth of 318atTF _ - - --Water table depth-- - SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line p/ LEACHING LINE, ❑ No. & Length of lines Total length/size U 1 1 FILTER BED ❑, Distance to nearest: Well Foundation Property Line —,SEEPAGE,PITS. I 1. P .0.0 Size Number SUMPS ~❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 D13trict. 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 subcontracting 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 mus'c for all r)quiz d ns pe tions;Complete drawing on re))''e/e/))se side. Signed X_ Title: —1—' Date: FOR DEPARTMENT USE ONLY ZPitApplication Accepts' Date -42--" Area 12— Pit or Grout Insliection by - Date Final Inspection by Date Additional Comments: Ae " �. / "1 �-1J/ O Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 4 .20 {,r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 } NFO A AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. ♦ EM 13-24(RW.,,. �OS. 00 (1,(t.. �! f.— I7—�'( ?1' 133`t