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• APPLICATION FOR PERMIT • �LLt V� SAN JOAQUIN LOCAL HEALTH DISTRICT tit 1601 E. HAZELTON AVE., STOCKTON, O • Telephone (2091 466-671 1 c °71989 PERMIT EXPIRES 1 YEAR FROM DATE ISL (Complete in Triplicate) LALHE#UH ff Apf l[N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereinn d Fp+ ksion is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu auons of the San Joaquin Local Health District. n/_ /,, ,,n /^,// Job Address /900 &0J) 9 LLVO� (10,4 t It Cityy/�-+/��yu///f, �nLLot Size 200)C29-) PM Owner's Name 60060 l0f✓ Address ft Soul �ar4a Phone 273 Contractor f,�lFst UA--2MA=T_ Address 3323 Fi riZ4 � License No.5 Phone 9/6 — Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER WIPECO Wa 7`' 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 SPECIFICATIO4fl ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation 1 Dia. of Well Casing 60 ❑ Domestic/Private 3?15ravel Pack 11 Tracy Type of Casing SUC Specifications F1 Public FI Other fl Delta Depth of Grout SealType of Grout 40�lsppv; I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump — H.P. State Work Well Destruction ❑ Well Diameter b Sealing Material (top 50'1 Cehot� Q 0 Depth LS0 z Filler Material (Below W') Z ItZ SDM TYPE OF SE IC WORK: NEW INSTALLATION I 1 REPAIR/A D IOr I INo septic system permitted if public sewer is Q available within 200 feet.) 0 Installation will serve: Residence_ Commercial_ Ot Number of living units: Number of bedrooms N 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number 10 SUMPS ❑ Distance to nearest: Well Foundation Property 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 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 workman's compensa- tion laws of California." The applicip ustt call for I requuy ins p tions. Complete drawing on r verse side. Signed X �A / ,[tom Title: Date: D NT USE ONLY Application Accepted by Date Ld Ar r / Pit or Grout Inspection b Date Final Inspection by DatA 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 20D9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I C H RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 11324(REV.v x 5) EH 1476 3—' C'� 1'a1 C�-1-