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{ ' APPLICATION FOR PER41111 Md I _•- SAN JOAQUIN LOCAL HEAL WWW=WU$WhTONAM ;I 1601 E. HAZEL T ON A Telephone (209) 466-6781 1 PERMIT EXPIRES 1'YEAR FROM DATE ISSU (Complete in Triplicate) DEC 1 0 1989 ' I,,g'NT�C��a�-&T1H Application is heiehy made to the San Joaquin Local Wealth District for a permit to construct and/or in�F1t1�i��her a application is made in compliance with San Joaquin County Ordinance No. 549 forsewage or No. 1862 for well/pump and thptft 6��Zf 1':Y"FaYbr'�sOhe San Joaquin Local Health District. ,, L I Job Address _L3" G&wf+ EL `Do,-oJb City Stg1_1A!_ Lot Size 10'K!fo' PM � 6 !I Owner's Name C kco,-. 0.s.A. ern c. Address c.0i Wt:ham �cy enami San rZumy" Ceti q4 S Phone 0-6y) 8< 2- / ! _1 q090-PI-e-Lo.hG Sat 2.fa Contractor Vt13awJ�tx9ctTrQ T��n,ala Address' Cor►�o .8� CSL 45t-ZaLicense No.4 f3`i3ffg /3 J _. Phone 67-f- "t, #?ZI TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ { DISTANCE TO NEAREST; SEPTIC TANK AkAvcu 1 SEWER LINES I i DISPOSAL FLD,444— PROP. LINE`:5F FOUNDATION uAGRICULTURE WELL OTHER WELLLAt�nom> PITS/SUMPS+-uL_.�yoee�n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ate' ID Dia. of Well Casing i IIQmost+�/ riveto ® Gravel Pack ❑ Tracy Type of Casing 5�kpA.r 491!of L Specifications 1-1 PublicW te, C] Other 171Delta Depth of Grout Seal O }28� Type of Grout 4c^ �-v ri o.r 4a r,'.5 I I Irrigation G6-Approx. Depth I I Eastern Surface Seal Installed by6e,5 thj Ui.c.-I^-s, Repair Work Done ❑ Type of Pump Po H.P, 00114- State Work Done_ -V0''1 Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION !1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is *� available within 200 feet.),Installation will serve: Residence_ Commercial_ Other 111 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 i Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size ; FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS C I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS- El-- I —I hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquincounty ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. i Home owner or licensed agent's signature certifies the following: I certify that in the + ' Y 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 q 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 mus call for all required i spa do s. Complete drawing on reverse side. Signed X Title: e 1` r $ ! Date: I FOR DEPARTMENT USE ONLY Application Accepted by aLAI-e Date Area � f i Pit or Grout Inspection b DateFinal Inspection by Dat��ICCb i Additional Comments: lrJ �j 0 I 11 Stk 466-6781 ❑ffdj 369-3621 ❑ Manteca 823-7104 ❑ racy E3i�-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 RECEIVED BY DATE PERMIT NO. INFO +.EH 1 >a-241REV.ii5f EH 1429 I