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APPLICATION FOR PERMIT 96 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PER ) OM DATE ISSUED APR - 6 1989 ( e in riplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Loca ealth atric or aper to construct and/or install the wBWRW&HEAL1F44$gW0LT,$ation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and th f At 1NFW&flp ftrM0V15tWuin Local Health District. -{- 'e �,, Job Address �� [ 5� �'� 1r `-^-^�V Cityt�ky� Lot Size �f/1( I/'(01 PM J—`�1HC� tJCQC�I Y' • C4 �f��,0F5'-lCf�`�' PhonPi C6-- �a Owner's Name u�Address Y] UnldG I Sfq-cq R,L.c;;Ek n v�33o T Dr.'d'0S Contractor Gxba u>afir �sCddress - cnr Ca 9YSTo License No.12'73 Phone C 41 �Lcjm TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation cA Dia. of Well Casing ZY16cA ❑ Domestic/Private A Gravel Pack ❑ Tracy Type of Casing P UG Specifications y, I') Public ❑uOther ❑ Delta Depth of Grout Seal C Type of Grout q�C1 CC,Me I I Irrigation 75 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction Well Diameter[,c2'/Inc�i Sealing Material (top 50') xV Alf ri Depth x yE en Filler Material (Below 50') TYPE OF SEPTIC ORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg �.p ��f�yc_ity�- No. Compartments PKG. TREATMENT PLT. ❑ �ENVIR `^+ EN-r -PTTPi r�--rylethTihltB� Distance to nearest: Well our anon ')"' Property Llr1aSION c� LEACHING LINE ❑ No. & Length of lines Total I gl}I FILTER BED ❑ Distance to nearest:. Weil.. Foundation Property Line SEEPAGE PITS I I Depth _l'�V lnan•6:cv� - Number SUMPS Ll Distance to nearest: RlN11Y '��.pp �„x Line DISPOSAL PONDS ❑ �ALRKTUD ISM I hereby certify that I have prepared this application a .II — Y-`►•iya�, with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health I trl 1 j 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 cenify 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/�9qq at cal for all required'in�sp'ec/Y¢'ons. mplete drawing on reverse side. Signed X /, QJ� iwn1',Lv1'T Title: I TVe o L' Q Jbate: USE NLY FO EPA T Application Accepted by Datej/� ��'� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stir 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 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 RECEIVED BY DATE PERMIT'NO. INFO L� ♦ EH 13&TREY.1/x5) S O KO -1/I(� O O� EH 1324 K Y 1 /