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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICIft 1601 E. HAZEL i ON AVL ,STOCKTON, CA n , ,, E I V E D Telephone (209) 466-6781 DEC 6 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENV1RU ' Vflr__NTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installlt&W UrwgapThis 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. / ,N/v E " -T- _6' Job Address 41"k, � � City Lot Size PM Owner's Name Address ` s*374one Contractor Address Q license No.l�,z Phon TYPE OF�PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR li�� 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 Bottofn s ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑,Tracy Type of Casing Specifications FI Public n Other Ll Delta Depth of Grout Seal Type of Grout r119ation br*VA9gj _& .Approx. DeptII I Eastern Su Seal Installed by _ Repair Work Done S---type of Pump ' H.P. �� State Work Done + Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material (Below 50') V TYPE OF SEPTIC WORK: NEW INSTALLATION I 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 w 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 Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: WeII _. Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. Home owner or Ii e a is 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 on in suchnner as to ecome 1 t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the ollowing: "I ce that i a e of the th' rmit is issued, I shall employ persons subject to workman's compensa- tion laws Califor ia." The app can; all re i ons. C plate drawing o e. Signed Title: Date: .9/2 FOR DEPARTMENT USE ONLY -7 Application Accepted by Date Area Pit or Grout Inspection by y.r Date Final Inspection by ate Additional Comments: ❑ Stk 466-6761 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 13.24(REV,1/n5) 1 ' `3 EH tI-28 l