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APPLICATION FOR PERMIT )N JOAQUIN LOCAL HEALTH DISTR JUL 9X991 601 E. HAZELTON AVE., STOCKTON, C Telephone 12091 466-6781 €NVIRQNMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERYIC�s (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application 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 "I'_C1'ne '!-,--V Dc')Ot City La ii ro") Lpt Size Q00 .nC • PM +y, Owner's Name U `l m-r Pddrasa T 0 •h Rd . ZST,ll'=o P no F:O : 7011 108 r1eiZ1.Contractor 7i � ^1 .1 ' 1.1-i ^ ''i Address 0-"? '11: (:^ 1 � 1.. O'JC ense No. ' one^1 . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ EST PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA LD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WDLL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom EC Manteca Dia. of Well Excavation Dia. of Well Casing All ❑ Domestic/Private M Gravel Pack ❑ Tracy Type of Casing SC$ A0 T:JC Specifications PI Public ❑ Other 1-1 Delta Depth of Grout Sealy.=iP S Type of Grout`P ^r1`.'... I laivation VEIrI_-'Abp,ox. Depth I I Eastern Surface Seal Installed by CP.-"1P'�'l: _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 ,-.O i.i i-1;0:."_-.,-I Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 1 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms a 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cer ifyr 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 Dihnict. 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 subcontracting 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 required inspections. Complete drawing on reverse side. Signed X - Title: t 0l�v`>-.�..- Date: FOR DEPARTMENT USE ONLY Application Accepted bylf� Date Are Pit or Grout Inspection by 111k e ;:�k Final Inspection Dattsr��-��S Additional Comments: ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Petmit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO JAAMM^O�U/Nl'TT OU E AMOUNT REMITTED JAS,H RECEIVED BY DATE oPERMIT'No. . EH 13 24 IaEV,11.51 v v EH I.20