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POICA(y)) APPLICATION FOR PERMIT roti ao 1 ,:�`W��SAN JOAQUIN LOCAL HEALTH DISTRICT PAY1E11[Tf ��WO. 1601 E. HAZELTON AVE., STOCKTON, CA REGEIVrD Telephone {209) 4665-6781 V � � PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED OCT 2 5 1988 Op`i��N��,'� (Complete in Triplicate) fiVVjRON er �c r y made to the San Joaquin Local Health District for a permit to construct and/or install the M q ��i;tibUf��Ripplication is e m co pliancy with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the 81V1��f the San Joaquin Local Health District. y Job Address 10 Y S J ''V City of Size PM ' 1 � / Owner's Name/ r �+ ddress ��1rC CC/ Phone Contractor ]� � � .t � Ma6c _ Address /`f/�-,��✓�E�3 ��D` __ License No.S�Vc,s- Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION D PUMP INSTALLATION;R- SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURt WELL OTHER WELL PITS/SUMPS_tN _ TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICAT ONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 Dia. of Well Casing EJ Domestic/Private Gravel Pack ❑ Tracy Type of Casing 1 7�'e-7 L Specifications {-I Public /"Other^WVA+ Ll Delta Depth of Grout Seal 1 V e Type of Grout �Tt t 1 Irrigation Approx. Deptq l 1 Eastern Surface Seal Installed by !W-.4c- Repair Work Done ❑ Type of Pump -Soidnf H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material iBelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION 1.1 DESTRUCTION i I,(No septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms LA 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 1 LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS l I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ; r 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 taws 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 must ca or all r e fns . Complete drawing on re side. Signed Title: Date: -0' FOR DEPARTMENT USE ONLY Application Accepted by Date r Area 7 - Pit or Grout Inspection by �7 f Date F4 � Final Inspection/by /� arw�' Date Additional Comments: `` '" ► ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 5 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 A RECEIVED BY DATE PERMIT'NO. 1� INFO �J` r.EH 13-241RE'V.1/951 - :�- c�z� y •� - 13� �. EH 14.2(5