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=� APPLICATION F'041[ I EMOIT SAN JOAQUIN LOCAL HEALTH DISTRICT I51-RIC3 16 01 E. HAZEL TON AVE.., STOCXTOi A� OAQUIN t4CI HEALTH V I I f wlaphotltl 1209) 466.6781 ENVIRONMENTAL � 1ER IT ISION PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDSPIECIA " � {CorTlplote 111 Triplicato) i 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. Job Address APPr()x 20 ` nth Of DpWlas & 24' 1 st 'Of .�k C City � Lot Size N/A _ PM Owner's Name . _.-pWi��xi Ci (b• Address 1765 Ca li L�y, Sacreumto Phone (916) M-1100 ' i Contractor Address 1386 E. BeTex St•, t Ocr-13>d License N03857 Phone(916) 662-4541 TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C] SYSTEM REPAIR 111 OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK NSA SEWER LINES 50' DISPOSAL FLD._WA<- PROP. LINE NSA FOUNDATION NSA AGRICULTURE WELL WA OTHER WELIf DLP �;PITS/SUMPS NSA I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- I la Industrial D Open Bottom C] Manteca Dia. of Well Excavation 10rr Dia. of Well Casing 411 I-] Domestic/Private IN Gravel Pack L] Tracy Type of Casing PVC Specifications 1-1 Public I:] Other IXl Delta Depth of Grout Seal 30, Type of Groull tie I i Irrigation __.Appfox: Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. _ State Work Done_ Well Destruction ❑ Well Diameter 10r' Sealing Material flop X)'1 (301) feat coymf- * 5%, henttrmj„I;p }� j: Depth—_ .55!.,.,._,._ Filler Material (Below 5101.(3(h),#3-&nb23= sand TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is E available within 200 feet.) I Installation will serve: Residence— Commercial Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line �J i LEACHING LINE Cl No. &length of lines _ . Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth -Size _ _ Number SUMPS LI Distance to nearest: Wral .__. Foundation Property Line DISPOSAL PONDS I-1 I hereby certify that I have prepared this application and thal the work will he done in accordance with San Joaquin county ordinances,-state laws, arid 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 permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.”Contra t r' hi i AIRFI gnature certifies the following: "I certify that in the performance of the work for which this permit is dI f WK�4W E� pensa- tion laws of California." ENVIRONMENTAL HEA�t H ©IV 1. The applicant mu for a TO i o omplete drawing on reverse side. SPECIAL PERM ' Signed X Title: ftesident Date: 2/15/89 `- FOR DEPARTMENT USE ONLY A lice ' n Accepted b f�f pP P Y �_ ____— Date Area Pit or Grout Inspectionby Date Final inspection by r Date 3 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 D Tracy a35-6385 l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT//EMITTER RECEIVED 6Y DATE PERMIT'NO. EN 14-25 Li 1"6j y� + � •Li ;