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s APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, C ; Telephone (209) 466-6781 � ��[`� PERMIT EXPIRES TYEAR FROM DATE IS �E (Complete in Triplicate) FEB 3 1989 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 Co u"nty Ordinance No.549 for sewage or No. 1862 for well/pump tl\l�dd.the,Rules.an�i.,Regulalio r s of the San Joaquin Local Health District. 'iic :ci'vfN� E!'r_H llfl F�R�1rl`i 1 SEWICrS Job Address _1 -(CnA6N 1 Irl City Lot Size PM c= Owner's Name Address � �y Phone Contra cto 1f Address . �+ �� 1 _ J3e' cense N046-Ye Phone -°� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION uk SYSTEM REPAIR ❑ 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 - i Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I N!Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Otherr F Delta Depth of Grout Seal Type of Groutr. p I'i Irrigation :_.Approx.:Depth I 1 Eastern Surface Seal Installed by _ it Repair Work'Done Type of Pump '' H.P. State Work pone _ — Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth + Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION 1.1 DESTRUCTION l I (No septic system permitted if public sewer is Ij available within 200 feet.) S Installation will serve: Residence_A Commercial_ Other 14 Number of living units: Number of bedrooms N 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—!L Property.Line ° Total len th/size i LEACHING LINE - �❑" No. & Length of lines - g FILTER BED ❑ Distance to nearest: Well Foundatiom,. Property Line SEEPAGE PITS l I Depth -Size Number SUMPS R Ll Distance to-nearest: ,Well Foundation 'Property Line DISPOSAL PONDS ❑ i I s 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 District. 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, 1 shall not employ any person in such mariner 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 applica mast- 811 for all regtJ O44"pections. Complete drawingon averse side. ff Sign X Title: Dater J_y TMENT USE ONLY —7 Application Accepted by FOR EPARDate " 16, 9 Area Pit or Grout Inspection by Date Final Inspection by 9'C Dat _ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C] 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 i IFEEO AMOUNT DUE 1 AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. ..I +.EH 1321 iREV.f KS) 1"Aol � aqEH 11-2a