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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT <br /> O Telephone (209) 466-6781 DECEIVED <br /> 0 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1IAR 13 1990 <br /> (Complete in Triplicate) Tultr Tc UIN COUNTY S <br /> Appl4inm5pliance <br /> hereby made to the San Joaquin Local Health Dist WUQ i !D"I t � <br /> madwith San Joaquin County Ordinance No.549 for dewasomom6=93 <br /> Local Health District. <br /> SPECIAL PERMIT <br /> Job Address �1 n City c?TaGk-m., Lot Size PM <br /> Owner's Name Fre-,4 1 L i 21`S Address T n. tpbC 7`�,_3 Y0 157'enr.k Cerhone !q 1,2-113bI <br /> Contractor L` Address a �r License No. 41'1E-4.70.70 Phone - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X b r,r�r:�-R,r,;� • cl) <br /> DISTAN SEW DISPOSAL FLD. PROP. LINE <br /> *�AGR ELL OTHER WELL PITS/SUMPS <br /> W#k <br /> INTENDED USEn PROBLE EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial PO 191 <br /> M Dia. of Well Excavation " i Dia. of Well Casing <br /> MEl Domestic/Private EllGravel PackXV ElTracy Type'&Casing-�L.n clL—r� g 2 Specifications <br /> I1 Public 111 Other n Delta Depth of Grout Seal Q0, Type of Grout <br /> I I Irrigation 24)Approx. Depth I I Eastern Surface Seal Installed by 0nMe.r-h<,-­,, <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done-= <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 50') Qr row ,2 t <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well_ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines — Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant muusQsst/t call for all re uireedQd inspections. Complete drawing on reverse side. T <br /> Signed X ye l�fr• ltt � '~- _ Title: ONNEF� Date: 3- a—Q!V <br /> FO PA T USE ONLY rl <br /> Application Accepted by _'� <br /> Date ..... zy Area 3 <br /> Pit or Grout Inspection by Date _ Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> EH 13-21(REV.r i n 51 <br /> INFO AMOUNT DUE AMOUNT REMITTED F1 RECEIVED BY DATE PERMIT'NO. <br /> + 35,M) 'W I/�� 3 ko ko1 S <br /> EH 11-2e Y <br /> l <br />