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APPLICATION FOR PERMIT �. 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA . Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) CSS Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein tdescri5ed.TI-TIplication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules andWR'.4atinraa the San Joaquin Local Health District. Q e ` . Job Address �Q.G+ //►►__ CjPrr�� City Lot Sizet PM Owner's Name 2` N. C a 61V sia,&651D 1a� _.,._ Address Phone a 10 Contractor A1 ddress JaC License No, 1 Phon 1 T TYPE OF WELL/PUMP: -» NEW WELL 9 WEI-L REPLACEMENT ❑ DESTRUCTION D � t .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.X!2 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS ` y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingpVcs Specifications 5 E7�(tA,e}fpy X Other ❑ Delta Depth of Grout Seal T pe of Grout�j�_�, VIII WApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ; ❑a Type of Pump H.P. State Work Done_ Well Destruction © Well Diameter Sealing Material (top 501 6 Depth Filler Material lBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ; 1 I Depth Size Number SUMPS E1 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 C�9fornia."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 Cafiforrdia." The applicant mus call fa It required i spections. Complete drawing on reverse side. Signed X % 't_o �, 00"e,-ro'e oo! .e,� C� Title: S Date: &,lIQ / 1988 r4crme, work pt" R DEPARTMENT USE ONLY Application Accepted by /�( ri,r Date Area 2 / Pit or Grout Inspection by J" Date Final Inspection by Date ✓ (J Additional Comments: r-c+-C-4 l.l. at ek`� CVQ4J c.$ o.., ILL. y ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 © Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazaiton Ave., P.O. Box 2009,Stk., CA 85201 FEEAMOUNT DUE AMOUNT+REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24(REV.tiK51 EH 14-29