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%001 rMIT L APPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH DISTRICT IV '.CLN f 1601 E. HAZELTON AVE., STOCKTON, CA !/ 1111V9I111 Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED MAY 18 1990 1 { (Complete in Triplicate) f �N1177�a `r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tFie V� > sCLWVh application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the R VIMf the San Joaquin LLocal Health District. Q 9J/ / Job Address 3 70/ pp3 , A- )C i c ity e/.� Lot Size PM C J� .5c� dK Pi Phone Owner's Nam A�d/d+�ressn L Contracto AddresspT/U!i License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR kr OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ LINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing L ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications LW Public FIOther f-1 Delta Depth of Grout Seal Type of Grout 1 Irrigation —Approx. Depth /II I Eastern Surface Seal Installed by _ Repair Work Done ;K Type of Pump H.P.�. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 fr Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) O 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 L SEPTIC TANK L1Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LLEACHING LINE ❑ - No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line L SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, andU/� 6. Home and regulations of the San Joaquin Local Health D3trict. 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 0 employ any person in such manner as to become subject to workman's compensation laws of California-"Contractor's hiring or sub-contracting signature P_ 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." ` 1� L The applic t call for all require nspect Cc plate drawing onr7 side. Signed X �.Q L�- Title: /p 0.5 Date: /7 /1,991� ` 6R DEPARTMENT USE ONLY Application Accepted by Ak� Date Area LPit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7100 ❑ Tracy 835-6385 LApplicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO L, EM 13-2/IREV.11.51 3 EH 1/-Ia •�7