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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1601 E. HAZELTON AVE.,•-STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 77 c;, � Ilcate) "k f in Trip'r p 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. ;2.3s'-- zf Jab Address API-4 2? –1 LG !/ City Lot Size Aa PM Owner's Name C and L Trac G'rOL1P Address 21060 ,Rainhow Dr I, CU ertin'CPhone (408 ) 99.6- 95014 8088 `Contractor Sal� Address ZSW 0I01 6-04.- License No."�ckyo Phone}TS___ -er y t 1 TYPE OF WEL !PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM"REPAIR ❑ r OTHER 9--' � o DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ,PROP. LINE FIQUNCATION _ AGRICULTURE WELL :OTHER WELL PITS/SUMPS ( A INTENDED USE( \ E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t� ❑ Industrial \\� ❑Fp.n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ''❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications��'� �n,f l 1 Public Ll Other fl DeIEa Depth of Grout Seal Type of Grout l � I i Irrigation -Approx Depth I ) Eastern Surface Seal Installed by" n- Repair Work Done ❑ Type of Pump H.P. State Work Done:RtQ _ GC i•1 hnrin fzs Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 —__ Jnr udy.. �Z Depth Filler Material (Below 501- Weal De ,g out.d aS requirec a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REP.AIR'lApDITION I ! DESTRUCTION I I INo septic system permitted if public sewer is ' available within 200 feet.) \ Installation will serve: Residence� Commercial Other 4 h Number of living units: Number of bo s 1 s Character of soil to a depth of 3 feet:' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Comparttrlents PKG, TREATMENT PLT, Cl Method of Disposal Distance to nearest:. Well Foundation Property.Line LEACHING LINE No. & Length of lines r 9 Total length/size FILTER 8ED Distance'to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS ❑ Dist c - ..rest: Well" Foundation Property Line DISPOSAL PONDS ❑ x. I 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. . i1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrflii is issued, I shall not r employ any person in such manner 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 applicant must call for a required inspections. Complete drawing on reverse side. r 4 Signed X Title:Pre S, dent , Frank' Lee & Date: 3-23-89 l Soriates FOR DEPART Application Accepted by Date Area Pit.or Grout Inspection by Date _-_ F1nal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 "° A Applicant - Return all copies to: Environmehtal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . i FEE INFO AMOUNT DUE = r AMOUNT REMITTED C RECEIVED BY DATE PERMIT ND. ! a j +.EH1N-2B 3-21 IREV.t i n 6) EH r o VB/, I 1 k