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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 PERWTISERVICES Application is haleby 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: 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.�/ � { ` / �}`�' j Job Address a -7 T y�3 N �. a f7 `�` Cit r a�' 1 _r 0 A S QQ /- s - p y�[Ot Size PM Owner's Name A C Q a� �ac `lt a.A'ddress S11 ML f Phone g � 3 � CantraDFeVr t E1 �,c1- S S Address Idty#D a JI p�, 1� \0(`4 V4ense No/ Z- L--'-"Phone� s^�s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR @!r' OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK 7,:5"-/©b SEWER LINES DISPOSAL FLO. 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 0-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I 1 Eastern Surface Seal Installed by _ Repair Work Done Rr' Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sua{iRg-Meariel Rop 691 fSlec L i�i.9�L .1 Depth Filler-AAatewaL{8elew *) S TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 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 will 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 1 I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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' rules and regulations of the San Joaquin Local Health Diltrict. 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."Contractors hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant^must call for al required inspections. Complete drawing on reverse side. Signed x �� Title: CtN u- +vim N Date:-),t �y CA r Vie �/J� FOR DEP—AR�TMENT USE ONLY / -Application Accepted by _ �' L ��L�z) Oate `ala' Area Pit or Grout Inspection by Date Final Inspection by AT/4c Date�•f Additional Comments: ❑ Stk 066.6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NFO AMDUNT DVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �.M f4261REV.t/x61