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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone Q091 466-6781 RECEIVED PERMIT EXPIRES TYEAR FROM DATE ISSUED NOV 0 t? 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 vy (,ftW.0 "k96"%n is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the I tl�nN� /1USdQ�In Local Health District. n EJO �f ,Q��Cff ff/6/f�C�� ; 4VIX Job Address -130853– S_ ENTERPRISE Rai ,C City ElqCA QN Lot Size PM Owner's Name F.RNP.ST M[?LLER Address _SAME _ Phone .-$:1$. Contelc j• Larsen PUMPS, Ilfgd,ress 509 TULLY RD_ License No.276660 Phone 529-2020 TYPE OF WELL/PUMP: NEW WELL 1R CE DESTRUCTION PUMP INSTALLATION X 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 ❑ Open Bottom [_1 Manteca Dia. of Well Excavation Dia. of Well Casing Xj Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public F] Other i1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation ---Approx. Depth i I Eastern Surface Seal Installed by _ W Repair Work Done ❑ Type of Pump .AC-VZ H.P, 3 /,§tate Work Done IEZ4 Q Well Destruction ❑ Well Diameter Sealing Material (top 501 O"O Depth Filler Material (Below 50'1 — w TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet-1 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I ] Depth Size _ Number SUMPS L.-1 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: "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 u call f r all r uire ctions. Complete drawing on re arse side. � Signed X Title: ;l�LC�J Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection b Dated o Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT AIDE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ♦ EH 1 -241REV.i/H51 35'0 5-vo _ �Ipti EH 144 •l -28 '"