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R" E ""'I'VED 4 ome APPLICATION FOR PERMIT %*Vl U L r}' SAN JOAQUIN LOCAL HEALTH DISTRICT NOV 2 7 1989 1501 E. HAZELTON AVE., STOCKTON, CA ENVIPO? ,im .ETAI IarALTF1 Telephone (209) 466-5781 " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERi"AlI Y/S%.R'V°'Cr 3 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/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 District. Job Address 80 City �� t� Lot Size f )t PM -1i M Owner's Name \++^ ` �+`i Address W_ _ mac. t i 5 '' Phone 4-7 7- 6`(6 6 Contractor 40 .� cwGi Address 'ZCZ'�✓2•'V -I'V License No. �`+ (�(a7 Phone 37 7�7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '2-,Cj DISPOSAL FLD. PROP. LINE (o FOUNDATION a AGRICULTURE WELL — OTHER WELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'I Public I7 Other Fl Delta Depth of Grout Seal%#��_'1_it Type of Grout__.,.__ _. I I Irrigation -__ Approx. Depth I I Eastern Surface Seal Installed by 6f441 Tu OP4& G�N+r,N1�s 31✓? S4r e2•i" Repair Work Done U Type of Pump H.P. State Work Done In 17`r rrc.. Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DE=STRUCTION I I (No septic system permitted if public sewer is 0 available within 200 feet) Installation will serve: Residence____ Commercial Other -J Number of living units: Number of bedrooms 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. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll 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 Di%trict. 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 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 applicant must call /for all required inspections. Complete drawing on reverse side. Signed X�//ilff 1�— Title: t�+�r. .1 "/ Data: TMENT USE ONLY Application Accepted by Date/r Area Pit or Grout Inspection by h-.-®-Y✓L Date ISh7l Final Inspection by � �_ _ Date Z/S 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 2009, Stk., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY 11 DATE PERMIT N0, + EH 1324 fREV.r in 51 !�- _ EH 14-26 C