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PAYMENT RECEIVED JAN JOAQUIN LOCAL HEALTH DISTRI 1601 E. HAZELTON AVE., STOCKTON, AUG 1 ? 1988 Telephone (209) 466-6781 A(J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f 1 4 Igigan ENVIRONMENTAL HEALTH (Complete in Triplicate) ENVIROMqEryNTApL�pgHdE�A�tLnT��.II ApplicatioRER"T//� VWAShe San Joaquin Local Health District for a permit to construct and/or install the "F( r'TiShYbf�s 4plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and' egu a he�n Joaquin Local Health District. Job Address -2/c,766 .� n(J1 ' Ciry 1 Lot Size PM Owner's Name/{LI- 1 1.�P [ h_ flM IO AI Address 261AA �nnt_'6 124 V16C qU Phone - Contractor r Address License No. Ph TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout_ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material fBelow 509 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO I (No stem permitted if public sewer is v/ i Installation will serve: Residence war hin 200 feet.)_ Commercial OttLe� Ky Number of living units: _ Number of bedrooms DD 1r V Character of soil to a depth of 3 feet: 0' - Water table depth _ SEPTIC TANK ❑ Type/Mfg Ity No. Compartments YI PKG. TREATMENT PLT.❑ Method of Disposal ■ Distance o t: u tion Property Line LEACHING LINE ❑ No. & Length o Total length/size FILTER BED ❑ Distance t r 1 Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to r elilk Well _ Foundation Property Lie 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 D3trict. 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 taws of California." Connector's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shelf employ persons subject to workman's compensa- tion laws of California." The applica ust call for all req/uJ�Ja, inspections. Complete drawing on reverse side / C� o Signed X _ 4�J�iL Title: kl Y�i�f7(." Date: 55' / (] 8 Application Accepted by FOR DEPARTMENT USE ONLY 7 '/� � ,3 Date Area Pit or Grout Inspection by Data Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 El Tracy 835-6385Applicant- Return all copies to: Environmental.HwIA.Permit/Services 1601 E. Hazelton Ave., P.O. Bor3006,Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED 5-4 K M FO RECEIVED 9Y DATE PERR'NO: N Mu • E (11".H ICA _ _ 1