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4 APPLICATION FOR PERMIT AYMENT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE., STOCKTON, CA MAY 2 6 1988 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALT9 {Complete in Triplicate) PERMIT1,SERVICES 04 Lf 0�ct yo 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 J-,/^}cz L 11) VILL RCF CfPJ7� City 451 -TO Lot Size PM i Owner's Name L/n1CZt_t) ?AID? LTD Address fob Contractor l�+� -T)w`- `foF Address 3 ~d OOV� License No. Ph ne��2�3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA S'cJI�— BAR-I 5 rIr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �� ,_T kl FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �D r,}�- .yZ�1A)chj' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 8n1F Specifications M Public ❑ Other f-1 Delta Depth of Grout Seal Type of Grout crr-4,x)_r_..._.__. I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ h� Well Destruction ❑ Well Diameter Sealing Material (top 501 X 7aIC- fi;pf_la6-:� .Depth Filler Material (Below 501 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is k r available within 200 feet.) Installation hw+iA '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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I� Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ 9 No. & Length of lines Total length/size -I FILTER BED /" �' ❑ Distance to nearest: Well Foundation Property Line IN 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 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 must call for all required inspections. Complete drawing on reverse side. Signed CS 7 ��'V'7 Title: c'� �^-�it�'.A 4'�i Date: �S I _ FOR DEPARTMENT USE ONLY Application Accepted by Date Area (� 1 Pit or Grout Inspection by Date Final Inspection by Date �73 Additional Comments: FKVfAJFd ❑ Stk 466-6781 ❑ doJi 369-36210 ❑ Manteca 823-7104 ❑ T cy 835-6385 i 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 CK RECEIVED BY DATE PERMIT'NO. INFO �j j� C J +.EH 13-24IREV. 51 , Co V• EH 14-28 \.J