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APPLICATION FOR PERMI-10 V` 5 SAN JOAQUIN LOCAL HEALTH DISTRICT RE C E I 1601 E. HAZELTON AVE., STOCKTON, CA AUG 15 1990 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEaENVIRONMENTAL HEALTH © (Complete in Triplicate) PERMIT/SERVICES ApplicHcea t y o the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application i3 made h San Joaquin County Ordinance No. 649 for sewage or No. 1662 rot well/pump and the Rules and Rogulahons of the San Joaquin Local trict. I' ., . �_ City `' ,1Lk�- or Siza . __—QPM -i -. Job Address rN..114AQ"i.� ��" � (-Z I�.f1J,✓t HJ(,ev _ Address I Owner's Name -D� r t '5+-,-L<�..r�. C 51- -��✓^^_L ddressg Z � - et$Zy No.SL� Q_ Phone-Zi_�/i.q6 � Contacto • � TYPE OF WELL,PUMP: NEW WELLS Z WELL REPLAC REPLACEMENT WELLS 11 �('�� (' PUMP INSTALLATION C SYSTEM REPAIR fl OTHER` Mel); DISTANCE TO NEAREST: SEPTIC TANK ___ SEWER LINES --- DISPOSAL FLD._. ROP. LINE — FOUNDATION AGRICULTURE WELL-_ —OTHER WELL _ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing _ C'1 Industrial _ UOpen (3ortont (7 Manteca pia. of Well Excavation . - r,��L..., - Type of Casin• _P�f c SC L._�JZ- Specifications �,! Domdstic/Private I1 Gravel Peck { ❑ Tracy tl �� 5 _ C o Of Grout 5,��_C� (' Public (Athero~ �� Delta Depth of Grout Seal .'Zwt Yp P - I I Inigauat :PApprox. Depth 1 I Eastern Surface Seal Installed by — -" Repair Work Done Z.1 Type of Pump _..,r H.P. _._____—_ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 '--- Depth Filler Material (Below 501 �_ _• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 (Noilseptic idlln 2{10 ermiremitted,f public sewer i3 Installation will serve: Residence— Commercial_ Other..r_ Number of living units: Number of bedrooms Character of soil to a depthAf 3 foot: . Water table depth - 11Ca aCit No. Compartments SEPTIC TANK Ll Type/Mfg p' y...__ PKG. TREATMENT PLT.f1 ? Method of Disposal Distance to nearest: Well ...__ — Foundation Property Line LEACHING LINE Cl No. & Length of lines _..__._ Total length/size— FILTER SED f-I Distance to nearest: Well - Foundation _........._- Property Line SEEPAGE PITS -- I I Depth -- - Size _— _. .—_-- Number . SUMPS LI Distance to nearest: well .__-..— Foundation __..-_ Property line Y� DISPOSAL PONDS CI I hereby certify that I have prepared this application and that the work will be done in accordance witr, San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin Local Health District. "I certify that in the performance of the work for wh ch this permit is issued. I shall mHome owner(it licensed agent's signature certifles the following: o workman's compensation laws of California." Contractor's hiring or sub-contracting signaun employ any person in such manner as to become subject t certifies the following: "I certify that in the performance of the work for which this per,nit is issued. I shallemploy persjns subject to workman's compens tipn laws of California." -}� The applicant r t call(o all req 'red ins etlons. Complete drawing on rnvnr1se side. e ,`�C Signed X Title: Gev�o_� Dare: :?V 4q FOR PARTUSE ONLY �- V- 2y-iv Date ` 3 i _._.. Area Application Accepted by _._.. - �---- I Pit or Grout Inspection by Date Final Inspection by Date _ Additional Comments: f-I Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 6237104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental 11441th Permit;Services 1601 E. Hazalton Ave.. P.O. (lox 2009, Srk.. CA 96201 FEE AMOUNT DUE AMOUNT REMITTEO CASA RECEIVED BY DATE PERMIT NO ' INFO l . EM 13.24'REV 4•n5. � --l.�.J�