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f f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA_ PAYMENT ' Telephone (209)'466-6781 REGEIVEr PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED ; (Complete in Triplicate) n C T 13 1988 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t��'9 f��^he�,re,in described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t1ileaatt�lJ l rpXn Joaquin Local Health District. PERMIT/SERVICES �1Llt��ad� 1 S© W, r ct City S o Lot Size 3 _S act PM D Job Address - , A �2a9, j Owner'sName � d tyeW dress Phone Contractor l' [91� Address /l101W*� �'&;;�Aiicense No. TYPE OF WELLIPUMP: NEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 171 OTHER DISTANCE TO NEAREST: SEPTIC TANK q� / SEWER LINES /001 DISPOSAL FLD` ._ PROP. LINE FOUNDATION -AGRICULTURE WELL?/rOD' OTHER WELL 00 PITS/SUMPS INTENDED USE TYPE OF WELLT PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 �r Ll Industrial 171 Open Bottom 11 Manteca Dia. of Well Excavation_ `�.__�. Dia. of Well Casing 04I eneeaTit:IPrivate 9 Gravel Pack ❑ Tracy Type of Casing c . /0 PiV_ Specifications {-1 Public �❑j Other ❑ Delta Depth of Grout Seal J VZ F - Type of Grout Ct I I Irrigation i5 . ZApprox. Depth I.l Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ['I ' REPAIR/ADDITION I 1 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other fr Number of living units: Number of bedrooms V' Character of soil to a depth of 3 feet: Water table depth 0 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 { I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 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 fo wing.''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 Cali ornia." The applit us call ar a quir i s ns:.Complete drawing on nnsreveerrsse side. Signed _ Title: ?�'C� ecsT' Date: rte'WZ $o 3Z FOR DEPARTMENT USE ONLY II Application Accepted by Date Ar ` Pit o Gro Inspection by Date L-�- Final Inspection Date �J Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. INFO �� ♦.EH 13-241pEV.1/951 �CS,t.��ppLl { EH 14-2d rt