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APPLICATION FOR PERMIT P1 �)y SAN JOAQUIN LOCAL HEALTH DISTRICT 'E0 1601 E. HAZEL T ON AVE., STOCKTON, CA APR 17 1989 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EN1fR0Ni ENTAL HEALTH (Complete in Triplicate) PERW/SEWICES uct and/or install the work n described. This cation is constr maddApplication s lwith Sano the Joaqu n County Ordinauin lHealth District for a nce No. 549 for sewage or permitto 1862 for wew pump and the Runes and IRegulationss of the San Joaquin macompliance Locale Health District- � � � City 'r[Gx tot Size PM L,�� Job Address Pik Owner's Name ,e Address43 4 �� "" �'� Contractor GG�a � License No. Phone Address TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION LJ PUMP INSTALLATION NK SYSTEM REPAIR D �OTTH•F��i- ❑ , Imo- SEWER LINES '-!__'__'<"''<_. _ DISPOSAL FLD....L,2r PROP. LINE DISTANCE TO-NEAREST: SEPTIC TA FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC Ti S E KDomestic/ dustrial EJ Bottom ❑ Manteca Dia. of Well Excavati p Dia.'of Well Casing Type of Casing Specifications !t� Private. Gravel Pack Tracy Type of Grout i ublic �Other ❑ Delta Depth of Grout Seal Yp I 1 irrigation 9-0—.-Approx. Depth i I Eastern Surface Seal Installed by r Repair Work Done C7 Type of Pump H P State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') permtTYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I (Noavaseptic sy t m feet.) if public sewer is r .. . Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK L1 Type/Mig Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line IS 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 Ll Distance to nearest: Welk �' FoundationProperty 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 Di§trict. " 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 signature employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's nslsub subject to workman's sub-contracting certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 tion laws of California." The applicant st call for req a nspections. Complete drawing on r arse side. ; Signed Title: Date: FO DEP TMENT USE ONLY Date Area Application Accepted by Date �7 Final Inspection by Date Pit or Grout Inspection-by _ Additional Comments: D T� ❑ Stk-466-6781 ❑ Lodi 3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 k FEE CK RECEIVED BY DATE PERMIT'NO- AMOUNT DUE AMOUNT REMITTED CASH INFO +.EH 13-24{REV.�iH51 Q EH 14-2e