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/ APPLICATION FOR PERMIT PAYMENT S JOAQUIN LOCAL HEALTH DISTRICT RECEiVED 1 E HAM—i ON AVE , STOCKTON, CA g 1988 • u Telephone (209) 4/613 - 3 410 o U U L - i PER IT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT jSERVICES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described This application is made in compliance with San Joaquin County Ordinance No 549 for sewage or No 1862 for weill pump and the Rules and Regulations of the San Joaquin Local Health District ¢f Job Address e r ��Qn I 1 Q�2Q6) City A Lot Size 6 PM Owner s Name /'n 1- A All T r _ — Address. f �-I u' AAC,l Phone Contractor 5 ' tR1,h -1I'1 L Address ~ MY Q License Na TYPE OF WELL/PUMP NEW WELL JR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial CJ Open Bottom ❑ Manteca Dia of Well Excavation_ _ Dia of Well Casing CI Domestic/Private L1 Gravel Pack [d Tracy Type of Casing 64H. yp VC Specifications Lu U public x Other r"�3 SAND t l Delta Depth of Grout Seal � rC su mcg Type of Grniit NFA Er .,�_ n jrnUanon Approx Depth I I Eastern Surface Sed] installed by > >' {/�, Repair Work Done L3 Type of Pump H P State Work Done Well Destruction1.7 Well Diameter Sealing Material (top 50) JX/ 07I1tol,/ �h!(3) Depth Filler Material (Below 50 l � TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION i i DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feat) 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 0 Type/Mfg Capacity No Compartments PKG TREATMENT PLT F1 Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No S Length of hoes Total length/sue FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS- 1 I Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Line DISPOSAL PONDS 0 1 hereby comfy 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, 1 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 signdtuff r certifies the following I certify that in the performance of the work for which this permit Is,asu�I employ pe ns subject to workman's comjaansa tion laws of California The applicant m t II for all required ins tions C rowing on reverse side Signed Title .64r`�" rt..rs I,kr a C Date FOR DEPARTMENT USE ONLY 9 / Application Accepted by _ -ye-- Data Pit or Grout inspection by ly" J ✓� Date �� Final Inspection by41 Date l Additional Comments ' ❑ Sik 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 83&GM85 Applicant- Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave , P 0 Box 2009, Stk , CA 95201 FEE AMOUNT OUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO INFO