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• APPLICATION FOR PERMIT . SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 MAY 0 2 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) `{I�/PUBLIC `(HEALTH �SERVICES �� Application is hereby made n the San Joaquin Local Health District fora permit to construct and/or inst 3jl lf��•�Qb}K'IfL18 r&ft1Yr Q.Qhl�'aR-ation 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 4/31 111 City S �^� Lot Size PM Owner's Name SkIl01Z Co. Address Po lfaX 5'6z3 CaYCOCc Phone y �� • Ma a, a Address License No. Phone Contractor �tHar TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1OTHER 13DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;, e).I- DISPOSAL FLD. PROP. LINE 1 FOUNDATION --A4I--A4AGRICULTURE WELL ..dt{il-- OTHER WELLN� PITS/SLUM INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (:,il E3 ❑Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /yL Specifications � � I'1 Public O(Other L1 Delta Depth of Grout Seal ^3r, Type of Grout A� / Ir 1 Irrigation —.Approx. Depth Ix Eastern Surface Seal Installed by - U' Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I available septic withm rmiitted if public sewer is r 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 c SEPTIC TANK ❑ Type/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 1 I Depth Size Number SUMPS L1 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, state laws, and rules and regulations of the San Joaquin Local-Health D3trict. 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 applicant all for all quired ins ctions. Complete drawing on reverse side. Signed X Title: cam•'/ 4 r/ Date: �•�A' FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ' Date � O Additional Comments: ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT NO. �. NFO EH 1334 IREV.1/x 51 I EH 14-26