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APPLICATION WOR PERMIT 16 SAN JOAQUIN LOCAL HEALTH DISTRICT � 1,7�C�� r 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED A O 1993 (Complete in Triplicate) Ef�Vllt��`v-VL4L HE1L'?i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein , �-r-% tlin s made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Reg IJ�i�".-�;??+i- rn Joaquin Local Health District. Job Address JZ 14 SO t'µ lel' s? City 5'300"VL Lot Size P\I �� 94 Lor Owner's Name 6iti,4 - Wog kr w Address MY S IJ• � a��a(r,' - _y0� Phone Contractor LG CJI^e- to4.4� Address �e100 Ctf �M V.11e OWLA2 aensRe No.�00 P^OrV X10 L fZy r00 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �4.U.. p-w DISTANCE TO NEAREST: SEPTIC TANK?100' SEWER LINES X2004 DISPOSAL FLD_*-t4V4% PROP. LIKE FOUNDATION^�•!O r AGRICULTURE WELLIIY"kl- OTHER WELL> Mt PITS/SU%!P� >L•v� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /tJ�L� ❑ Industrial POk ❑ Open BottomQ. ❑ Manteca /^_ Dia. of Well Excavation Dia. of Weil ❑ Domestic/Private ❑ Gravel PackN1.1 EI Tracy �IK Type of Casing Specifications t * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ L Well Destruction ❑ Well Diameter Sealing Material (top 50'1 a Depth Filler Material (Below 50'1 _ A TYPSEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system -„p w , , r is available withint f �N L'`U In5f, tion will serve: Residence_ Commercial_ Other PUBLI EA;_T: SERVICI C f Number of living units: _ Number of bedrooms ENVIRONMENTAL HEALTH DIVISOS 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_—PAYMENT LEACHING LINEA ❑ No. & Length of lines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Property Line 993 _ Ate` N JOAO!�IN rnr r SEEPAGE PITS AIN I I Depth Size Number��1, HEALTT_H aERyjVES SUMPS 0 Distance to nearest: Well Foundation Property Linecuy H�LTH DIVISIQ\J DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanaYS. state laws, aml rules and regulations of the San Joaquin Local Health D3trict. 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, 1 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 workmaD's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X \1c.�.,T� ��. / Title: Date: �aUL�.YW cI oCk9� Date: �S 1 FOR DEPARTMENT USE ONLY Application Accepted by _ o Date Area3�c Pit or Grout Inspection by �K Data S "c3 Final Inspection by Dated l-3 Additional Comments: l ❑ 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., 5/ NFO AMOUNT DUE AMOUNT REMITTED I CASH I RECEIVED BY /DATE /] PERMIT NO. •51 + EH 13-24(REV.it x 5) OZ7 3•D EH 1426 Ol J I r