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4 APPLICATION .FOR PERMIT _ SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT ., 1601 E. HAZELTON AVE., STOCKTON, CA i Telephone (209) 466-6781 RECEIVE® PERMIT EXPIRES TYEAR FROM DATE ISSUED SEP 12 1990 (Complete in Triplicate) SAN JOAQUIN COUNTY- Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theW SERVICES s I�gMro made in compliance with San Joaquin Ck unty Ordinance No.549 for sewage or No. 1862 for well/pump and the R%5 n Joaquin Local Health District. F k r Job Address t � � 1kj ye- �� Cit L Lot Size PM Owner's Name et-ek, �,1 H '� Address V�N�`a I �C ,Phone Contractor * ! Address 1� License N Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION PUMP INSTALLAT�IO�N�.❑.y � SYSTEM REPAIR Ll OTHER ❑ DISTANCE TO NEAREST:. SEPTIC TANK -/ - SEWER LINES Z<14- 90 DISPOSAL FLD. PROP. LINE FOUNDATION, AGRICULTURE WELL OTHER WELL" PITS/SUMPS _ INTENDED-L'1SEy`"i-`TllPf=OF'CNELL= PRO BL'E11+1 l[FiEA"'"CONSTRUCTIOfi'SPECIFIGATIONS ❑ Industrial=-r -----❑ Open-Bottom - -. ❑ Manteca- e- Dia-of-Well Excavation Dia. of Well Casin r� g-.- Domestic/Private tl�avel Pack # ❑ Tracy Type of Casing- Y G Specifications c M Public n OthQr/r2fr j; F1 Delta Depth of Grout Seal � j Type of Grout I I Irrigation f/l`�Afpprro-xx.. Depth r I I Eastern Surface Seal Installed by_ � I.LA _ Repair Work Done ❑ Type of Pump F H.P.: k 'State Work Done_ Well Destruction ❑ Well Diameter ` Sealing Material ftop.501 Depth Filler Material-tBelorti 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1 1. DESTRUCTION I.I Wo.septic system permitted if public sewer is n #`' �' ' available within 200 feet.) `C Installation will serve: Residence Commercial Other " � 1 �- Number of living units: Number of bedrooms Character of soll to a depth of 3 feet: Water table depth SEPTIC`TANK ❑ Type/Mfg ` tCapauity No. Compartments PKG. TREATMENT PLT. ❑ ! # Method of Disposal Distance to nearest: Well # .Foundation r Property.Line L � LEACHING LINE ❑ No. & Len'gth of fines' Total length/size FILTER BED EIy Distance to nearest: ;W, ell Foundation Property Line �.i SEEPAGE-PITS l I Depth Size 4 ` r' Number SUMPS ❑ Distance' to nearest: A Well Foundation Property Line DISPOSAL PONDS ❑ f j _ - I hereby certify that I have prepared this application and that the-wofk-will-bedone'in accordance with San Joaquin cbunty•ordinances,Tstate-Iaws,=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 shalt nb _ 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X C� f Title: $t d IA Date: FOR.DEPARTMENT USE ONLY Application Accepted by Date / — < y Area 'V Pit or Grout Inspection by Date Final 178C by 2 Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Maniacs' 823-7A G Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EV.� INFO sY AMOUNT DUE H' AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. t + EH 1324IR /e � l�/ EM 14.26 / 253