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SCANrJ- E _=APPLIC—ATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTQN AVE., STpCKTON, CA— Telephone (209) 466-6781 !��®ko PERMIT EXPIRES TYEAR FROM DATE ISSU 4� {Complete in Triplicate) 0CT, 1989 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein-desc�ibed��,51�,- ic fon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and L' l�I l tl � FJ aquin - Local Health District. ^� PERMIT 1 SERVICES Job Address /7 ,334, ,3 3 (+1 ! _ Citv.kocl�4D Lot Size PM Owner's Name Y/C Address Phone . Contractor Pkp< e Address1_1714�06O-1:icense No. Phone 6 F3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 2� SYSTEM REPAIR- ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �€ 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 f`1 Public CI Other f 3 Delta Depth of Grout Seal Type of Grout _ Irrigation __Approx. Depth l I Eastern Surface Seal installed by _ Repair Work Done ❑ Type of Pump H.P. 20 6 State Work Done, Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 �. Depth Filler Material (Below 501 -Q TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l_I DESTRUCTION l 1 INo 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 ❑ hype/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 LI 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," late laws, and rules and regulations of the San Joaquin Local Health District. \ f 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 1 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 st tali o all required inspections. Complete drawing on reverse side. _ Signed X Title: Date: . " FO ARTMENT US ONLY y ,� Application Accepted by Date .1 �" Area / Pit or Grout Inspection by Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE%%,, PERMIT NO. +.EH13-24iREV.I/H51 �� }j•—{�—K —15& EH 14-28 V 1 I