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APPLICATION FOR PERMIT • A°,Jud' 310'ol.01 >o1J'� OAQUIN LOCAL HEALTH DISTRICT .4 �U,01 E. HAZELTON AVE., STOCKTON, CA MAY 1 5 1991 Telephone (209) 466-6781 SCS Ll- � I&PIRES 1 YEAR FROM DATE ISSUED ENVIRONMENT— PERM C�fVIRONMENT (� 3 PERMIT/SERVICES (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 5?-7-0-3 W�r I m Jf CityI Yp`WI Lot Size PM +' lulyAln�t Qaer- Owner's Name n � � Address?n5 N. Ca►If ��(ld $ Phone ContractorW6T 1'IF`':m4,k Address X733rJf1!TA U &rtkArl License No.C57 C754975Phone 9NO fo3SIPP 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 tt ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 54h 40 pVL - - Specifications 11 Public W Other Mal rWI!'❑ Delta Depth of Grout Seal N'; Type Type of Grout Ce_1n 1 I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by R AWhA#- - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Q04I'I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ( ' Installation will serve: Residence_ Commercial_ Other V \. Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth V 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 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 District. - 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 l� `� Ct-7 u -�"7'� Title: (/�PQ` FOR DEPARTMENT USE ONLY y Application Accepted by `-' Date Are. Date � • 2 'Y' IG' Tial Inspection by Date Pit k,Gou Inspection by Additional Comments: i ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 035-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE gMOUNT DUEJ�A�MOUNTREMITTDOK RECEIVED 9r' DATE PERMIYNO. �Jl �.EH 1324 IREV.1/851 �� • 5�;5> jt;': .y- EH 14-M