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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT F?I�YMENT - ! 1601 E. HAZELTON AVE., STOCKTON, CA RECEtYEO Telephone (209) 466-6781 NOV 10 1988 ' PERMIT EXPIRES tYEAR FROM DATE ISSUED ' _ _ (Complete in Triplicate) ENVIRONMENTAL HEALTH ! `� P�Rf1/��TrSERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descritted.TRis application is made in compliance with San.Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin r Local Health=District--O` " I Job Address , �0 ' r 7,JeACG/w Tj�(g�(� City / Lot Size PM '7-,eA a Y Co(-rr-G„i f r-y M 9fliell°}� / SP!7 L f �t) A VE)W 7J�C y 6,- Name l�Q aD9 n AddressS3s-- `sIpID I� _ Phone SPI_CYr_,� i a'P s .�'l-s r HVe)-6 JF ao9 Contractor Address -S��k�^� CIS- License No. 9__7_6 Phone1;9S"87��c� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI�ONJ" ❑ SYSTEM REPAIR ❑ OTHER^C SOIL 8p0elwlc_5 I DISTANCE TO NEAREST: SEPTIC.TANK rr�f �l SEWER LINES �d z DISPDSAL FLD._ 9D ) �� _ PROP. LINE FOUNDATION ---.L� AGRECULTURE WELL OTHER WELL 0 PITS/SUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom q Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private D Gravel Pack ,Tracy Type of Casing Specifications M Public Ll Other i F1 Delta Depth of Grout Seal l O r C>� /•IFNT cc+ Type of Grout4-1—OZ Aarlw_� I 1 Irrigation 2QApprox. Depth I i Eastern Surface Seal Installed by rCM(I� Repair Work Done 0 �Tpy�pef Pump H.P. State Work Done_ Well Destruction ❑ r Diameter __—"�'!<Jr1 t IP_n n/Mt±zJ7 A-L Sealing Material (top 50'l �e_TL4AJ,0 Ct_Z ,17_ Ld c ,�fN7a✓ir y� SA+1Pc.0A70�_- Depth- Filler Material (Below 50') - TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAIR/ADDITION l 1 DESTRUCTION [ I (No septic system permitted if public sewer is Installation will serve: Residence� Commercial___ Other available within 200 feet./ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' (} Water table depth v SEPTIC TANK L1 Type/Mfg. Capacity No, Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal ' Distance to nearest: WellFoundation Property line t LEACHING LINE ❑ No. &,Length of lines Total length/size ./� FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS i I Depth Size Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line 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 m ' rules and regulations of the San Joaquin Local Health Di§trict. V 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 I 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 Calif I .' The applica u Call for all re vire in do Complete drawing on rev std r Signed Title: Date: �I FOR DEPARTMENT USE,4', Application Accepted by �Q Date aavvvv Area Pit or Grout Inspection by d_ Z Date ;> _ Final Inspection by Date�O d . . x Additional Comments: ❑ Stk 466-6781 EJ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE Op f INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY +{}� / jDrA�TE (/ PERMIT'N�°Or.� .* EH 1428IflEV.I/✓I 51 3 UU 5. I 1!'�/ I�O 30C•b