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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 DECEIVED PERMIT EXPIRES 1'YEAR FROM DATE ISSUED APR — 6 1989 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wQWW&}ejEALTO.$EW&Totion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th fN A4 fN tiMMfMeMVrjVQ*uin Local Health District. Job Address [XJ4. City Lot Size Z00 X 0/ PM /D[1nI1d Crbc1� C=�' �� ,moi Owner's Name_";i�Co 1ntriG� r�PY1C Address h L�ArtfGf'�4�G1 � C4 �tj Q�"� X Phon I Slot t� � tiC �j� n �a ,t6Dr,: bs f t, Contractor G ta32�r� �rRe �1S8ddress [sit- Gq 9q6Z_ License No.%N�l3 _Phone TYPE OF WELL/PUMP: NEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I I 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 r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation z irtc d Dia. of Well Casing 116CA I ❑ Domestic/Private XGravel Pack ❑ Tracy Type of Casing vG Specifications 1-1 Public ❑ Other H Delta Depth of Grout Se ,al 0 c: Type of Grout,? c'- I 1 Irrigation 5_Approx. Depth l I Eastern Surface Seal Installed byh Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter 1J 121c- Sealing Material (top 50') X- j n ot-f' Depth x t CC- Filler Material (Below 501 —_ TYPE OF SEPTIC ORK: NEW INSTALLATION i l 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 Number of living units: Number of bedrooms f\ Character of soil to a depth of 3 feet: Water table depth \ � SEPTIC TANK ❑ Type/Mfg cit __�� No. Compartments._ PKG. TREATMENT PLT. ❑ Meth 1tI ZMQNME3� > Distance to nearest: Well Foundation Property L�JSII .: ., LEACHING LINE ❑ No. & Length of lines Total I ne g[h sl FILTER BED ❑ Distance to nearest:, WeIL- Foundation Property Line SEEPAGE PITS I I Depth _EMMA _ Number SUMPS ❑ Distance to nearest: 2"111411111w! N 1111111M=- A Line DISPOSAL PONDS ❑ . I hereby certify that I have prepared this application Istne I I �with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Locai Health 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 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 rrAst cal) for all required inspec ions. mplete drawing o/n'+reverse side . Signed X Title: C-`�'t l r UkS�6;5ate: L Q l FO.05 EPA T USE NLY Application Accepted by Date G Are 13-3 Pit or Grout Inspection b Date Final Inspection by Date L M i Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71D4 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f I FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO I,EH 13-24(REV.t i H 5) EH 14-28