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APPLICATION FOR PERMIT . 'SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT �. 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVE 1 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ASR - 5 1989 tlCo fete in Triplicate) SAN JOAQUIN COUNTY 2q,r S�- ClPUBLIC HEALTH SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install t If`�INf1� N1KK1ddft PILT"0sVJ f#(�Vn is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin " Local Health District. 5��,g /S'1—ZL rLf/�/ 9&E ftP�-0.1 "�p2�0 j✓O I.�inJ}� a qF' R'��I"l�i�i L�MFiNCeYSize Job Address Nr of Hwy IZ &�.{ PM 5T Owner's Nam. - Sffdp 9110 I 019! Address 1,77-7-1 + Phone Contracto y� 1T1Pet License Ivo.,;-_�_L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER,7�-T61S_r 69"ZJ-6.5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing ❑ Domestic/Private LI Gravel Pack El Tracy , 'y Type of Casing Specifications M Public S Other r-9f AFEV74t419 Delta" Depth of Grout Seal Type of Grout __-. .[ I I Irrigation _.-Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ ° Well Destruction ❑ Y_ V Diameter 6;u Sealing Material (top 501 6w 097 dl!� rf` Depth f r Filler Material (Below 50') /ISD 6P Z2? 1 ��} TYPE OF SERTIC.WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i l DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) r installation will serve: Residence— Commercial— Other f _ Number of living units: Number of bedrooms i> "Character of soil to a depth of 3 feet: ; Water table depth "'✓Tv'1 SEPTIC TANK ❑ Type/Mfg I 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 tornearest: 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 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 pensation laws of California Contractors hiring or sub-contracting signature employ any person in such manner as to become subject to workman's comr{ 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." L The applicant call for all; ed inspections. Complete drawing on reverse side. Signed X Title: Alza `f"7r 6,CoL-56fS7 Date: FOR DEPARTIMENT USE ONLY Q Application Accepted by Data / Area Pit or Grout �In�sppection by Date Final Inspection by Dat ! Additional�Corrimehts: ❑ Stk 466.6781 ❑ Lodi 3116-362'1 (71Manteca 823-71 El Tracy 835-6385 Applicant - Return all copies to: Environental ealth PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I H RECEIVED BY DATE PERMIT•NO. INFO + EH 13-24IREV.r/Kn) . EH 14-28 _ �+