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J APPLICATION FOR PERMIT ,. I I �AQUIN LOCAL HEALTH DISTRICT .,aI ��L�1,yv r�� �a ��1WA E' SON AVE., STOCKTON, CA L' ;,�Zj1��{�Q'��1j1�VQione (209) 466-6781 Calr10IS1 0& hi4'fiMiT EXPIRES 1'YEAR FROM DATE ISSUED NOV 07 7990 t�0aS (Complete In Triplicate) ENVIRONNeRat-lulin App on is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dp -M� s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu ations Local Health District. /�/� Job Address %�1 n �r /"! � 57-i City Lot Size • PM Owner's Name �1A��t( 2 ��! �I Address 0 Y"�� I I l -J Contracto f447ddress 72g �f '�'70_icense No. Phone TYPE OF WELL/PUMP: NEW WELL,9- WELL REPOACIETIE ❑ DESTRUCTION ❑ r PUMP INSTALLATION ❑_ SYSTEM REPAIR ❑ OTIjER DISTANCE TO NEAREST: SEPTIC TANK-I IOCO f SEWER LINES DISPOSAL FLD. N PROP. LINE FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom `S1 Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack /❑'Tracy Type of Casing rioy/c_ Specifications 1'1 Public )YOthiv v gnu' C1 Delta Depth of Grout Seal Type of Grout"C I I Irrigation //__''''A�tpprox. Depth I I Eastern Surface Seal Installed by r _ Repair Work Done 0 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 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 of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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 �""Fou�ndation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 Di1trict. 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 applic t st call f all req 'ed inspections. Complete drawing on rev se side. VA Signed X Title: ICitQ ate: //- .fiit��Ge FO DEPARTMENT U ONLY 'a►� a Application Accepted by . m 1 `f lys Date l �`� `' Area q Pit or Grout Inspppecti(pnJ bX Date 4) Final Inspection by L` Lvt�� Date l L U Additional Comments: W ❑ 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 CK RECEIVED BY DATE PERMIT'NO. INFO A�CAS/H EH 13-24(REV.r i n 5) EH 14-26 � ' ' 0 / '.<� (I /•'��' ��