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n APPLICATION FOR PERMIT EEiE Q SAN JOAQUIN LOCAL HEALTH DISTRICT AUG 2 0 1990 1601 E. HAZELTON AVE„ STOCKTON, CA Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES p (Complete in Triplicate) P ation is heielsy made to the San Joaquin Local Health District for a permit to construct and/or install the work(C� ::"Cgap spy; is 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 Health District. Job Address —/,00,2e) 's /(J' �k )e City Lot Size PM Owner's Name A Address 4�0; IS4 7612 r�`� Phone . A _ Contractor 4w1rAddress License No.. STT Phone TYPE OF WELLIPUMP: a NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INS7ALL47iON 0 SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE C] 1 dustrial ` Domestic/Private F -I Plrblie I i Irrigation Repair Work Done 0 Well Destruction ❑ WORK: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom 0.fvl6n�toca T Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack d Tracy Type of Casing Specifications fl Other FI Delta Depth of Grout Seal Type of Grout _ _. Approx. Depth I i Eastern Surface Seal Installed by Type of Pump H. P. State Work Done Well Diamefbr rf Sealing Material (top 50'1 Depth . __ _ Filler Material (Below 50) _ NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No seplio system permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ , i Other Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation Method of Disposal Property Line NG LINE 0 No. & Length of lines Total length/size— BED ❑ Distance to nearest: Well J Foundation Property Line SEEPAGE PITS I i Depth _- _Size Number SUMPS 11 Distance to nearest: Well Foundation Property Line biSJ POSAL PONDS ❑ F I hereby cenify 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 Di§trict. 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 ceitifies the fello ng: '1 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 to The appli call for all requi inspactio . Com to drawing on v a side. Signed This, Date: R DEPARTM NT USE ONLY Application Accepted by Date ' " A Pit Grout Inspection by Date Final Inspection by Datr Additit ional Comments: ❑Stk 4564781 ❑ Lodi 364-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63035 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ♦ EH 13.24 {Rt V. i/x 5) EH 1420 FEE IN FO AMOUNT DUE AMOUNT REMITTED C CASH RECEIVED 6Y DATE PERMIT' NO. M i J �I