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V$k�,6.&&1i UV APPLICATION FOR PERMIT MAR 9 1987 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ENVIROMENTAL HEALTH Telephone 12091 466-6781 PERMITAERVICES PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r. (Complete in Triplicate) 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. R v Job Address '/ U�S �l� �� City Lot Size PM Owners Name _ell,./.S C®N5Address _II 1 ��L 1�� one ".S c 40*71E�e �, �p, ! Contractor Address_0_1c2� ZWZAG J� License No. 1,9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION jbR.FPA+09L-J3,W0WSfEM REPAIR ❑ OTHER ❑ " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE y --'-FOUNDATION "�,--AGRICULTUREWELL—. OTHER WELL�- -PITWSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .. ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing' ' Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing + Specifications I ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Syrface Seal Installed by I Repair Work Done ❑ Type oftPump�f i H.P. �7 State Work Done RUL.� Well Destruction ❑ Wlell'Di ter' Sealing Material (top 501 -�_g� i Depth-T"�"'; '• Filler Material {Below 5017 }Y]p $/1� TYPE OF SEPTIC WORK: NEW INSTALLATIOWM REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is ! available W thin 200 feet.) Installation will serve: Residence". C6iiGnercial.-..:.-_Other Number of living units: Numbet'of.bedrooms 'Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.,Compartments PKG. TREATMENT PLT. ❑ Method of Disposal I Distance to nearest:----Well- Foundation - """�P operly Line i 4 LEACHING LINE ❑ No. & Length of lines -Total length/size ; f FILTER SED ❑ Distance to nearest: Well Foundation Property Line I , SEEPAGE PITS- ❑ Depth Size Number 4; SUMPS : - ,-- - q --Distance to nearest:' -Well z 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 s II for all r i ed inspections. Complete drawing on revs ide. i i Signed )�`�� °Z�-� Titley / Date: i 1 FOR DEPARTMENT USE ONLY I Application Accepted b p Y Date 3 Area ; Pit or Grout Inspection Date Final Inspection by Date / i s Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I: 4 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 E INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT•NO. + EH 13 (REV.1/a 5) EH 1428