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APPLICATION FOR PERMIT MXEIVED y SAN JOAQUIN LOCAL HEALTH-DISTRICT U Q 3 i9g0 1601 E. HAZETON AVE., .STOCKTON, CA Telephgne'i209)'466-6781 _ ENVIRONMENTAL HEALTH, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES j ,(Complete,in Triplicate) '• .� Application is hereby rtlade 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 Na. 1862 for Well/pump and the Rules and Regulations of the San Joaquin Local Health District. t Job Address Cit � Y- / Lot Size. PM 1 , Owner's Name �A1/�i - )n�t' rAddress tom - c � Phone Contractor ` , Address License No.r'fh�Phone ¢ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEMS REPAIR t OTHER ❑ 1 l _"_"DTSTAf CE"TO NEAREST-SEPTIC TANK _- SEWER LINES �--� �? DISPOSAL-FLD: PROP. LINE•-••-- FOUNDATION _ AGRICULTURE WELL 1 OTHER WELL PITS/SUMPS _ - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ElIndustrial -� 13Open Bottom -�❑ Manteca Dia. of Well Excavation Dia. of Well Casing •� _V'Domestic/Private ❑ V Gravel Pack ❑ Trac T I ype of Casing n Specifications f1 Public f_T Other F Delta Depth of Grodt seal Type of Grout--- I I I Irrigation ( _ Approx. Depth I I Eastern Surface Seal Installed.by Repair Work Done ❑ Type of Pump If __ H.P. �'N Tom` r _'State Work Done Well Destruction ❑ Well Diameter 1 el Sealing Material (top 501 I Depth o/52?7 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 j available within 200 feet.) Installation will serve: Residence__ Commercial Other t ' Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: _r Water table-depth SEPTIC TANK ❑ Type/Mfg _ _ Capacity .-' _ No. Compartments _ C PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ Property Line _ r LEACHING LINE V ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: �z Well Foundation Property Line SEEPAGE PITS- I I Depth Size _ _ Number SUMPS---S N --Ll-Distance to-neaies}:-r"Well-- Foundation's--m= Property-L-ine - - rj- *.-c DISPOSAL PONDS ❑ // I hereby certify that I have.pr©pared 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.L'ocal Health District. Homeowner-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 nom 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 Cali ia." •I `- � The apptic t call for all req r d inspect' ns. mplete drawing on rever side. Signed,X _ Title: ji C"',ckF,�- -_ Date: -- r FOR DEPARTMENT USE ONLY" Application Accepted by `�^�'�- 1 _— 'Date Pit or Grout Inspection Date Final Inspection by Ll1LLL!!L _— Date! Additional Comments: u Stk 466-6781 ❑ Lodi 369-3621 I ❑ Manteca 823-7104 n Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By, DATE PERMIT'NO. ..EH14-211REV.ri+t51 INFO C�, -7-q-90ll'� Y-) �. 17 EH 14.28 �-11