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APPLICATION FOR PERMIT PAYMENT �. �.�O��°$�N JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209)-466-6781 OCT 7 1988 PERMIT EXPIRES TYEAR FROM DATE ISSUED . oP �� A 0 10 (Complete in Triplicate) NYIRpONMTEfSN�TQAA�/L{�^H�ECALTA t Applicata x is hered�r a to the San Joaquin Local Health District for a permit to construct and/or install the wol4c% I�SL`1ti�622t'"Phis application is made in compliance ith San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin Local Health District. Job Address go/ sou-,q/ 6�`Zf`G ZX/4�F City J Lot Size !� PM AVw Owner' ame /n�X4 �./��L �L,& Address o/ S, C1wr� Z410 ZO -1 Phone 209 J60 } 'Contractor OWAI Address M5 F NgRM, y�C License No. �1Z�� Phlone W9 AMS7 / L TYPE OF/WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ 1_Manvto tVj1 Wei PUMP INSTALLATION ❑ 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 ❑ Industrial C1 Open Bottom El Manteca Dia. of Well Ex avatt n g Dia. of Well Casing ❑ Domestic/Private � Gravel Pack ❑ Tracy Type of Casin Sr-6• 11C Specifications Cf.'w d wtV -' r'1 Public 1=1 Other ❑ Delta Depth of Grou Seal Typ of GroutoC/� + I I Irrigation -Approx. Depth I I Eastern Surface Seal I Called � Ed � Repair Work Done ❑ Type of Pump H.P. tateork Done� Well Destruction I Well Diameter Sealing Material Itop ► C Lv Alza ani ' LG Depth 70 Filler Material (Belor C TYPE OF SEPTI ORK: NEW INSTALLATION 1.1 REPAIRIADDITIONI D CTION I l {Nol'septic tem permitted if public sewer is \ available ithin 200 feet.) Installation will serve: Residence Commercial_ Other I' I Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑.. Type/Mfg Cap ity No. Compartments PKG. TREATMENT.PLT. ❑;� Method of Disposal Distance to nearest: (141/etA� o dation' Property Line LEACHING EINE ❑: No. & Length of lines / Total length/size I� - FILTER BED Clrl Distance to nearest: el Folin tion Property Line I SEEPAGE PITS i I,. Depth 1ze _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑" I hereby certify that I have prepared this application and that the ork 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 perrtait is issued, I shall not P employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or stab-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall a ploy persons subject to workman's compensa- tion laws of California." �f�/'7ZGel�Y! Q � The applica st call f I r ed inspections. Complete drawing on reverse sid8" Signed A � Title: Date: /o I _ _ FOR DEPARTMENT USE ONLY, Q II Application Accepted by D to Areae i Pit or Grout Inspection by Date Final Inspection.by :11 Date f Additional Comments: SAN JOAQUIN LOCAL HEALTH DISTRICT ��. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ MantecaCs�a DIVISION Applicant - Return all copies to: Environmental Health Permit/Services$05C"IpFAE-RAU-Pox 2009, Stk., CA 95241 f FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. �1 I r' + EH 1341(REV.tix5) �UV 3s /� EH 14-26 �cc�..JJJJ-------�� i6 1 / as I 1