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APPLICATION FOR PERMIT D w f lV_ 61 SAN JOAQUIN LOCAL HEALTH DISTRIC 1601 E. HAZE' TON AVE., STOCKTON, CA Telephone (209) 466.6781 FEg 171989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,,,,, y (Complete in Triplicate) •t,. ..ENVIpRERMR gEgVICES`TM. Application is hereby made to the San Joaquin Local Health District for a permit to construct end/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 Rules and Regulations of the San Joaquin Local Health Distnct:"` - ''On' 'IImL�LC ..x _ Job Address [� \` r,►C�fnT(��' City � ! Lot Size PM Owner's Name ��/+ XC&I—M f8 "Address 12/y/J "�r—�t �^--t ', n.'1�1 .: Phone i- I Conbactor Address License No. Phomild TYPE OF WELL/PUMP: NEW WELLX, WELL REPLACEMENT ❑ DESTRUCTION-❑.��. .PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER }buJ� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. �LINE —•- —�-+- - FOUNDATION AGRICULTURE WELL "' OTHER WELL PITS/SUMPS JIINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /( F ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavatkm Die. of Well Casing ❑ Domestic/Private Gravel Pack ❑Tracy Type of Casingm CVe� Specifications ❑ Public l✓tel✓��❑ Other 13Delta Depth of Grout Seal AtfA.t+t>^$— Type of Grout C1Irrigation VO/,,�Approx. Depth "-�` ❑� Eastern Surface Seal Installed by- EAr4Rri -' /d Repair Work Done El Type of Pump SU17 H.P. State Woork Done Well Destruction ❑ Well Diameter Sealing Material (top 50') 2 �SftCF ��"'^} W — s Depth Filler Material (Below SY). �/06v 0_e V� qI in \: TYPEOFSE IC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is - available within 200 feet.) Installation will some; Residence_ Commercial_. Other- - Number of.living units:_ Number of bedrooms 0 Character of sail to a depth of 3 feet: Water table depth r I SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments V PKG. TREATMENT PLT.❑ Method of Disposal If Distance to nearest: Well Foundation Property Line (r I LEACHING LINE ' ❑ No. & Length of lines Total length/size II FILTER BED ❑ Distance to nearest.- Well Foundation Property Line l SEEPAGE PITS ❑ Depth t Size Number SUMPS - ❑ Distance to nearest: Well - Foundation '•Property Line TDISPOSAl'PaNDS"". ❑_ 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 irules and regulations of the San Joaquin Local Health District. - I 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 shag 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 Califomia." r,. The applicant m t call for all requi ed inspectiods. Complete drawing on reverse side. Signed X 7gla- •, Date: - pprJrR DEPART ENT US ONLY _j�(] , fApplication Accept by - Date Z�,,�/ k✓"z Area Pit or Grout Inspection by _L�L.�L Dam Final Inspectiotrby i LA16.' Dated I A9 r ` Additional Comments: - f ❑ Sik 466-6787 ❑ Lodi 369-3621 ❑ Manteca SZ!-7104 ❑Tracy 835.6M ,. Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hamlton Ave., P.O. Box 2009, Stk., CA 95201 FEEAMOUNT-DUE - AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO ♦EH r3.24 IRR.I A5 .. OC9 Z� :! T •.• EH 1Lm