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_ APPLICATION FOR PERMIT 1E SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED AUG 2 N 1988 s iComplete in Triplicate) Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the 9Ny;AP MW1gA-TWE tion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules a Tl %R,"C"San Joaquin Local Health District. mem p Job Address mew jg"' z�,E'�'•m '5" - -city, Lot Size �`'ip , PM Owner's Name tL/t'!!�r/ Address 6r/ Al l AY ?VX I 57 -- Ph m-46_05 aww i6w 7ROV'r- 0910 Contractor _ i 1�- Address fJ License Not_fPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTP ER X IY9Q�Y��-,�/�EL1 DISTANCE TO NEAREST: SEPTIC TANK /t'X1-F SEWER LINES -� DISPOSAL FLD. PROP. LINE _A1, FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation fn.., Dia. of Well Casing �2 ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing :W 40 MA� Specifications 1-1 Public 6ther WIVM Delta Depth of Grout Seal 9-0_4 4Type of Grout 11�l 7� I 1 Irrigation W..Approx. Depth ,Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump - H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 1 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 SEPTIC TANK ❑ Type/Mfg Capacity, No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property.Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property'Line DISPOSAL PONDS -. ❑- 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." The applicant all far a# r ire spec ' mplete drawing on reverse side.. Signed X - Title: LDate: /19, FOR DEPARTMENT USE ONLY Application Accepted by __ Date Pit nr Gr Inspection by G µ Daie Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. INFO a.EH 13-21(REV. 5) _ �S• �vQ -p� EH 14-26 ,. -