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APPLICATION FOR PERMIT 1 SAN JOAQUIN LOCAL HEALTH DISTRI' 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 D PERMIT EXPIRES 1'YEAR FROM D TE I U (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wcjrk heroin 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 Districts ��,r� f.i �S ;; 11 Job Address �0� �—a_ v`�eu-� C��+P City fin*/L/o oze d 2�r I =F PM U_L o� Owner's Name C� LA Address Ro1 i-,y elone 640 Contractor All ! Address CZ ZMQff 61'X License No r i TYPE OF WELL/PUMP: NEW WELL X )" n%lCr WELL REPLACEMENT ❑ DESTRUCTION ❑ .�Sum' PUMP INSTALLATIO'N ❑ uetk SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK kA� SEWER LINES (CO� DISPOSAL FLD.� PROP. LINE !V FOUNDATION ,+pi sAGRICULTURE WELL HJT` OTHER WELL�t� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �(I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tionDia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack' . 1 ❑ Tracy Type of Casing Specifications j M Public *X Other�tta n Delta Depth of Grout Seal a Type of Grout I I Irrigation WApprox. Depth I ] Eastern Surface Seal Installed by ^ _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501. R Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 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 r SEEPAGE PITS 1 I Depth Size Number SUMPS 0 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: "1 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 applica;K2must call for all requi d inspections. Complete drawing onreverseside. Signed X Title: f— 4 Date: 02-161-91 r7` —161— !q 1 E R DEP TMENT USE ONLY Application Accepted by Date / Gv �Pit or Grout Inspection by Date � ZO f Final Inspection b � Date VII2/ Additional Comments: O 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 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE ( PERMIT'NO. 113-241REV.tin51 V (•�� y.� -0� f EH 144-28 (J 1 ^\vv