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F APPLICATION FOR PERMIT gay SAN JOAQUIN LOCAL HEALTH DISTRICT '1601 E. HAZEL T ON AVE,; STOCKTON, CA Telephone 12091 466-6781 MAR 2 2 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t: i (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMIT/SERVICES r Application is hereby made to the San Joaquin Local Health District for a permit to construct and/orinstall the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpunip and the Rules and Regulations of the San Joaquin. Local Health District. may} Job Address f�CV Ea4 6K&J 11 n e Kt&d 7 CityrZLLI Lot Size �'�""'h' + 'PM 1 Owner's Name ►"yM I W(Y_Vi2[11fm Address,3ft w'1AUMJnk,1k__! I Kt' Phone CJf f)5 ZfpA0 Contractor �R�i�IN t Ill W Address yR Yt 1►E Lice � nse No."6` 'f!2L J'PhonA 37*-9' D TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION u ( 1 k PUMP INSTALLATION''''0 SYSTEM REPAIR ❑ i OTHER 0 N ITlM.1 rJb ,5btL.BbQr �� rat f DISTANCE TO NEAREST: SEPTIC TANK _Jm mg SEWER LINES DISPOSAL FLO. I L41 PROP. LINE L0 FOUNDATION 5.12' AGRICULTURE WELL_-5-1-40-LICOTHER WELL BIKE PITS/SUMPS •5'f1Lc` I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I E] Industrial C1 Open Bottom ❑ Manteca Dia. of Well Exca�tion / Dia. of Well Casing 9~ i.r Domestic/Private G Grave! Pack XT racy Type of Casing G Specifications Public 1—1 Other Cl Delta Depth of Grout Seat 3 Brd�_ Type of Grout —AlA LH?L Q!!! i ! Irnydtion 26�Approx. Depth ' I I Eastern Surface Seal Installed by W2MLt5f2 4[i - � Repair Work Done i✓ Type of Pump ! H.P. State Work Done Well Destruction C Well Diameter Sealing Material Itop 501 Depth Filler Material 18elow SO') �1 T OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I I DESTRUCTION i i (No septic system permitted if_pubfic sewer is .available within 200 fe Installation will se • Residence Commercial _ Other Number of living units: mber of bedrooms Character of soil to a depth ata feet: Water table depth p SEPTIC TANK ❑ Type/Mfg Ca No. Compartments f PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well !o tion Property Line I` LEACHING LINE C No. & Length ones Total lesize i FILTER BED ❑ Di sr to nearest: Well Foundation Property Lute ! SEEPAGE PITS I i Depth' Size Number SUMPS L) Distance to nearest: Well Foundation :Property Line DIS Al_ PONDS 7 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, andel; rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pertnii 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 Califomia." The appficant usi l for 11 req a spections. Complete drawing on reverse side. r Signed X "—� " Title: t- �1 t f ' Date: DR DEPARTMENT-USE ONLY �l l Application Accepted by Date r Ate � p i Pit or Grout Inspection by ace - Final Inspectionby ��^-a-t'C _ Data Additional Comments: r't/`� a/ Ur w Z / f ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 7104 ❑Trety 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2004, Stk., CA 95201 FEE'IlN�F�t)/ AMOUNT DUE AMOUNT REMITTED -CA5 /RECEIVED BY DATE PERMIt-NO. EN �9-S4IRE'11.+•KS,I'/!w/I . J ./ y� � f r.:r' -