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f APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466.6781 NOV 17 1988 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMITISERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein des ribed.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No: 1882 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.�/ /\ .,I Job Address a 7 T y`�' - " � L�` t, is City �%-��EOL Size F6 A S' PM Owner's Name 7m'ee A C Q -a^N6-aC to `�t)Cddres�s! S a (Q �r� Phone79 -Z 3 1 ContraOFe✓' r l� �n V' c� S S Address I AY �1 15 �. F (O(`1 ULfisense No� Z- G �Phone7y�`�/3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Oq-' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 7,f- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done lie� Type of Pump H.P. State Work Dam,7 z Well Destruction 13Well Diameter Sealing S4848 liep 5 ');4A l...iJt x Depth Feer-Mawpial i6olew-S01 TYPE OF SEPTIC WORK: NEW INSTALLATION I 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 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. & 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 ❑ t I hereby certify that 1 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 Di3trict. 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:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compansa- tine laws of California." The applicant must call for al required inspections. Complete drawing on reverse side. Signed XC Title: � �� Date:�b"V �7FOR DEPARTMENT USE ONLY Application Accepted by Date ` a'� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 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, Sik., CA 95201 INFO AMOUNT DUES AMOUNT REMITTED CASH RECENED BY DATE PERMIT NO. 00 ♦.EH 13.201REV.irx5l f�1� llVll�� 5 �\ Sg' 3 EN N-M �..J