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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT V 1601 E. HAZEL T ON AVE., STOCKTON, CA V Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SAN 12 1990 I 1 (Complete in Triplicate) ENVIRot Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worlP� �� dl:tLTAie-opplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and'144, San Joaquin Local Health District. t Job Address 1 700 City Lot Size PM Owner's Name )�t J- /i'*&QIZ 011L Address..}�-� - Phone Contractor Address&",5a.,2,- d— 2 '30 License No4AIC35i!i Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION K SYSTEM REPAIR C1 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 T ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i V-Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications i 1`1 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —Approx. Depth 11 Easternj� Surface Seal Installed by Repair Work Done U Type of Pump � H.P. AState Work Done R`r Well Destruction ❑ Well Diameter Sealing Material (top 50'1 _W Depth Filler Material (Below 50'1 _ �} TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION 1 I DESTRUCTION I 1 INo septic system permitted if public sewer is d available within 200 feet.) 4 i 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Yv PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest— W611 Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines _ _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS —1-1-A,Depth SizeNumber I _ i SUMPS FIDistance to nearest: Well Foundation.—"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." Contractors 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 mut all for MEee .red inspections. Complete drawing on reverse side. ,/ Signed X_ _ `_ __......_ Title: A19-1— Date: r-7 r�a O�EPARTMENT USE ONLY t Application Accepted by A Y.�'f� Date f _fV, Area r Pit or Grout Inspection by Date Final Inspection by Date_ f/ J/(� � Additional Comments: x ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 /FEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. .-EH1 3-241REV.FiN5l OJLC�� f EH 10-2a