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w APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HEALTH DISTRICT s f 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 RECEIV4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 2 6 1989 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work1 � (}Cation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules n 1 t o t l�S�raquin Local Health District. Job Address 9 �7 DF LIMA RO, _ ___ __-__ City5_1VCk"7;2.A_f Lot Size _2+AC+?h� PM Owner'sName �If_[ .SCI-1,&0AEL. Address /7QQ Z!<9_F V /,4_MDDFS%� Phone 11 Lof ContracteU`t I ddres S• l O License No S /xV Phonea4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT )K DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ — — OTHER ❑ DISTANCE TO NEAREST:,SEPTIC TANK M t`7 SEWER LINES 1• DISPOSAL FLDl �PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation la Dia. of Well Casing 19,Domestic/Private "04-Gravel Pack ❑ Tracy Type of CasingPyr Specifications I'] Public f_1 Other ,Delta Depth of Grout Sea�_Fl Type of Grout��L Nd._, I I Irrigation ��' i�pprox. Depth { I Eastern Surface Seal Installed by.- Repair y-Repair Work Done ❑ Type of Pump H.P. State Work Done _ \- Well Destruction ' ❑ Well Diameter Sealing Material (top 50') \ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] 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 V Number of living units: Number of bedrooms 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 Property Line t„ I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS ❑ 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 DiMrict. 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: "1 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 applic us allor all r uired inspections. Complete drawing on r arse sid r Signed X Title: f, 4Date: F,f�R DEPARTMENT US NLY Application Accepted by /dE�,(Q Date Area -2 /-F Pit orout nspection b Date -� Final Inspection by Date Additional Comments: �`" '�� 4 ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-710,V ❑ racy 63 5 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 INFO AMOUNT DUE AMOUNT RE ED CASH RECEIVED BY DATE j�PPERMIT/*NO. +. 3 2 14 INEV.1/951 /'r 00 EH