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•APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA �� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEIMAR 12 1990 (Complete in Triplicate) SAN JO,�IAlp�QgpUiPll (;111; 1(y Application is hereby made to the San Joaquin Local Health District for a permit to construct and This This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ w4N1d t AYtI a �tle,fA$11't1113i11tltlte San Joaquin Local Health District. �//.J� ,(/�� f Job Address __ [ X131 /�/4 ,' " E City// �'e^/ Lot Size le Slt " PM PZ Owner's Name / �n�fj�(// / ( -n Address �� &Iet 7'�Z`S �O"' CAq C�j Phone Contractor��sST/1A7mnt Address .JZ Jk d License NoOLS --Z'�c_Phone `t '"�%! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L4 So I41rir r DISTANCE TO NEAREST: SEPTIC TANK SFWrn I INrS 1)I1:110e:Al I1 n 1911• I INI FOUNDATION —.__ - AGRICULTURE WELL 11114111 WIII VITS SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS I1 Industrial [.1 Open Bottom ❑ Manteca Dia. of Well Excavation a�. Dia. of Well Casing I I Domestic/Private I Gravel Packk Cl Tracy Type of Casing. Aleldi: Specifications I Public Jed Other.Sod/`cr, H Delta Depth of Grout Seal Type of Grout�f'i rid I I Irrigation -__ Approx. Depth I 1 Eastern S dace Seal Installed by --------?------ Repai, Work Done I l Type of PumP •1f1°-_______ H.P. /✓ State Work Done .,ro Despurn,:1•. . - Well f)�.Innot I - _- $r•aling k atelier (1,11, N)1 Depth Filler Material (Below 50'1 --- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number or living units: __. Number of bedrooms Character of soil to a depth of 3 feet: ___----.Water table depth SEPTIC TANK L1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. (a Method of Disposal Distance to nearest: Well Foundation Property Line — LEACHING LINE ❑ No. & Length of lines Total length/size------- FILTER ength/size ___FILTER BED I I Distance to nearest: Well Foundation__ Property Line SEEPAGE PITS -� __..I I Depth _____ SizeNumber ._ —_ SUMPS I I 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 DiMrict. 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 must call for all requiredigaFactions. Complete drawing on reverse side. } 4' 1 (/ Signed X i�� u_. Title: Date: ?0 — FOR,DEPARTMEN USE ONLY Application Accepted by _ ��% - Date - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — ❑ Stk 4666781 ❑ 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 gMOUNT DUE AMOUNT REMITTED �CAKS RECEIVED BY DATE PERMIT'NO. INFO 1113341 REV.11N51 H 14M