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" APPLICATION FOR PERMIT i SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E. HAZE T ON AVE., STOCKTON, CA Telephone (249) 466-6781 V PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in .Triplicate) FEB 2 `_' 1990 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the,,,ta /1tignpf�tit1Q San Joaquin Local Health District. h nn . Job Address .3035-013/1/4/ City 7AAQV Lot Size PM CA �qsu Owner's Name 1� i�Q!LIPcSL�3/2 Address 91 .7- Phone / P-0. Pax 567 IP ContractorBDCKER DRII�i,S INC. Address Cart c Cz-ty,f, CO 8003Zicense No.0263675W— Phone Fa—M-92-86r1_7 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑3 M0,V1Jo� &.o PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERSoil ��`'If?„f,�.fr S DISTANCE TO NEAREST: SEPTIC.TANK CLOD � 7 SEWER LINES DISPOSAL FLD. PROP. LINE 11;e FOUNDATION AGRICULTURE WELL Al OTHER WELL a� 5 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 ❑ Industrial 171 Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l-1 Public %'Other ❑ Delta Depth of Grout Seal �.S7 �. Type of Grout_r_e/o l,!,V 6 i I Irrigation /;-()Approx. Depth t I Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 T Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I 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 t 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 D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line � SEEPAGE PITS I I Depth Size _ Number SUMPS L1 Distance to nearest:.- Well - Foundation Property Line DISPOSAL PONDS El 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 Dis;trjct. 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,1 shall employ persons subject to workman's compensa- tion laws of California." The appliccaantt must call for all�reqrui spections. Complete drawing on reverse side. ;I Signed Title: Vice;Presidents Date: J30 990 F EP ENT USE ONLY Application Accepted by Date A f C� 'Pit or Grout Inspection b �� p y� r� Date/ —Le) Pe Y ata Final Ins action b Additional Comments: ❑ Stk 466-6781 ❑ 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 I�INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. I aEH13-21(RE4r.t/x5) i O� ��o �� ' EH 14-28 I F