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-- '` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT RE ce,vEo 4 1601 E. HAZEL T ON AVE., STOCKTON, CA NOV 2 D 1989 Telephone (209) 466-6781 ENV11gpNMENT r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERjV�I�fa�� .��ALTtj ), (Complete in Triplicate) � ' J 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. k 2. 5�'o t N k . _ Job Address c sS lzlf�lGtiY Q 0 !fS� rt y �(Gtr` � Mv Zoq"�02{� i 1 11�� Lot Size PM Zaq—�rro� Owner's Name r I 'S 47'C. D�T ,)SJfAddress it kelTo 44 __ -.-� .3�[ of � /"t/r.�V Phone 117 "&ZQ-?)�l Contractor Wt S itn�(�f 1 Address License No. ab • Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑ 1l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER s 'n9s ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack' ❑ Tracy Type of Casing Specifications F1 Public fel Other Cl Delta Depth of Grout Seal Type of Grout I _ I I I Irrigation —.-Approx. Depth [ I Eastern Surface Seal Installed by Repair,Work Done ❑ Type of Pump ± H.P. State Work Well Destruction ❑ Well Diameter " eating Mater' fiery-6f}� �hQI¢ 7Q ®llG4 y �Q�, ©1 1r11p�) Depth I Filler Material (Below 50') TYPE OF SEPTI ORK: NEW INSTALLATION available within 200 feet.)I I REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is 1 I 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 SEPTIC TANK ❑ Type/Mfg :1 Ca acit i P Y No. Compartments PKG, TREATMENT PLT. ❑ I . Method of Disposal Distance to nI earest: Well Foundation Property Line LEACHING LINE ❑ No. & LengthIof lines r Total length/size FILTER BED ❑ Distance to nearest:' Well Foundation Property Line 1I SEEPAGE PITS I I Depth ( Size Number j6 SUMPS Ll Distance to nearest: Well Foundation Property Line ` r 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." j The applica ust call f r a eq d i s F tions. Complete drawing on ;Verse side. ; Signed X i/� Title: I Date: II /"t 13 on TMENT USE ONLY Application Accepted by F r Date J r rea - - ! Pit or Grout Inspection by DateFinal Inspection by T f on Date Additional Comments: t ❑ Stk 466-6781 ❑ Lodi 369-3621 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385 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 INFO RECEIVED BY DATE PERMIT'NO. +.EH 13-24 1REV.t i 9 51