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APPLICATION FOR PERMITj SAN JOAQUIN LOCAL HEALTH DISTRICT '' 1601 E. HAZELTON AVE., STOCKTON, CA E(C'E IV`F" Telephone {209) 466-6781 J U L 0 3 199n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTf- ' (Complete in Triplicate) PERMIT/SE VICE 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 1FO-41 Hoed ed R __ City Lot Size PM Owner's Name DOUG LARSON Address 4688 E. Clarksdale Acafn o Phone z 17754 N. Hwy. 88 Contractor GDRhY i ng--Pllmn_- R Irr Address I orkef Ord, Ca No. 309031 ---Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 50 SYSTEM REPAIR ❑ OTHER ❑ /s I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i tNTENDED'CJSf'�"`' TYPE -WELD �PROBL`EM�AREA"`�CONSTRUCTiON"SPEC1ffCATIONS—,—i"" �-�-' ❑ Industrial ❑ Open Bottom ❑ Manteca,_ Dia. of Well Excavation Dia. of Well Casing 4 ' ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ,; Type of Casing Specifications } I'l Public Cl Other 11 Delta i Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern' _Surface Seal installed by _ Repair Work Done f_7 Type of Pump 5_.__511b,_/_ H'P- 5 ' State Work Done_ Well Destruction ❑ Well Diameter _Sealing Material (top 50') Depth 1 Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITIONC1 DESTRUCTION I i (No septic system permitted if public sewer is r 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: e € _Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance,-to-nearest:—Well;-----Founda#ion;T--- — Property Line SEEPAGE PITS C I Depth Size _ Number SUMPS L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! r M 1 =xI hereby-certify that-1-have-prepared this.application and that;the-work will be done in accordance with San Joaquin-cbunty"ordinances,-state-laws;-and—. rules and regulations of the San Joaquin Local Health DiMrict. Home owner or licensed nt'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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followi : I ertify 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 Cali The applicant f r required inspections. Complete drawing on reverse side. }III I Signed X (Title: 13k1) `_ Date: 06/29/90 � I FOR DEPARTMENT USE ONLY i 1 Application Accepted by Date �. �� 6 Area Z 2— Pit Pit or Grout Inspection by Date Final Inspection b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I 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 BY DATE PERMIT'NO. ItJFO - q10-17S)l a.EH 13-21 IREV.1/H5f *� t •, 7 [" _'� /�'17S! EH 14-26 LJ t