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APPLICATION FOR PERMIT kf a / • SAN JOAQUIN LOCAL HEALTH DISTRI(;T T01111111E 1601 E. HAZELTON AVE., STOCKTON, CATelephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUN 011990 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the i lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the R es n Joaquin Local Health District. Job Address y V �� City Vie? 34 Own 's Name ss 1 ,`t W S PhoneilqT Contract ddressi ©1?:I,�k (I Z 7 License No. Phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 t"1 Public ❑ Other l ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation _..Approx. De th I I Eastern Surf e Seal Installed by _ Repair Work Done V/ 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 (1-- 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 of living units: Number of bedrooms 'k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ T ype/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 1 Depth Size _ Number SUMPS ❑ 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 regulation e n Joaquin Local Health Di$trict. Home owner or ' ensed agent' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any P so n in such manler as to become subject orkman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the llowi g:`"l certi!p4hat in t pe ormanc f e work for which thi permit,is issued,I shall employ persons subject to workman's compensa- tion laws Califo ia." The appl' a f all requ' d omplet drawing o de. 1_ n SignedTitle: Date: • DEPARTMENT USE ONLY Application Accepted by Date llK Area e Pit or Grout Inspection by Date Final Inspection by Date 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 t� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. 1\ INFO /^ CASH . EH 13-24 MEV.t i H 5) 35.00 C-4 EH 14-Mr