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Y. APPLICATION FOR PERMIT s. SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E. HAZEL i ON AVE., STOCKTON, CA Telephorle (209) 466-6781 PAYMENT PER.MIT EXPIRES 1 YEAR FROM DATE ISSUED RECEIVED iComplete in Tri licatelFEB 15 1990 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the �c�ef f i T sF plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Joaquin Local Health District. Z�—D�#p� �3 ENVIRONMENTAL HEALTi-t VIAVIS10N Job Address J` 1 �1 City Lot Size PM [� 3 a 7 , `Pao 415- 3� ? Owner's Name ►�+ � Address l% ra H-� I G 9 4 5,1 1 _ --r�c �t� ��jj 1 9 Contractor��_ - Address � L1 r G License No. S Phone=f[ V ; TYPE OF WELL/PUMP: NEW WELL ❑ WIFIM R_ffPLA1EMt1TrE1 DESTRUCTION ❑ PUMP INSTALLATION L) SYST> M REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK (bOO SEWER LINES PQ? ! E DISPOSAL FLD._ PROP. LINE C�+ FOUNDATION ' AGRICULTURE WELLS OTHER WELL- d PITS/SUMPS kX' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion G Dia. of Well Casing 1 +�9 Domesticl Private Gravel Pack LJ Tracy Type of Casing vC- Specifications � MAe)ST�y . M Public ❑ Other Delta Depth of Grout Seal �' 3`a T Re of Grout..-,fig i I Irrigation Jrb Approx. Depth I I Eastern Surface Seal Installed by�� k Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 �I ck, C LX-_JC 15 Depth Filler Material (Below 50') -- I TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION l 1 DESTRUCTION I 1 -(No septic system permitted if public sewer is available within 200 feet.l , Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth y ' 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 l I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 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 fo wing: "I certify that in the performance of the work for which this permit is issue I shall employ persons subject to orkman's c mpensa- tion laws o a forma." H �t+—�i L.Ol7��c5t�1� L�� 5 The ap cant ust call for a requ- i tions. Complete drawing on reverse side.ti 3 S w 1duJ Wra� �U )AIA ] / / Signe?X \ Title: l 5AA�.��A�5) Date: a�� 90 9y6DO DoT-" 1V- �o, t''�D�� a� FOR DEPARTMENT USE ONLY Application Accepted by A-ZDate /r( Q Area Pit or Grout Inspection by Date Final Inspection by Date 3 �d Additional Comments: E ❑ Sik 466-6781 ❑ Lodi 369-3621 V Iff Manteca 823-7104 ❑ Tracy 835- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ^'}�� CASH r.� K +.EH 16-24{qEV.1,e 51 f /D �� 1/G o,..-H 1 4 EH 14-28 I `� [ e7 NNN