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C r), APPLICATION FOR PERMIT UNiewmd0UN1YFMC LOCAL HEALTH DISTRICT BNVIAONMBNTALMLTH DD 1 H FLTON AVE., STOCKTON, CA SPECIAL PERMIT Telephone (209) 466.6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ji (Complete in Triplicate) / u G 1990 Application is hereby made to the San Joaquin Local Health District for a1 permit to construct and/or install the work herein described.This application is made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rul Local Health District. ftWatiorlcAf Me$dD Joagein j PERMIT/SERVICES { Job Address City5-LZ<C Uri Lot Size Ply Owner's Name (-t'/� ✓r IG Address Phone FRsr r //T Gf Contractor SL Ttir-r+ Address Llx7 T License No. €yam Phone TYPE OF WELL/PUMR NEW WELL WELL REPLACEMENT 17 DESTRUCTION Cl PUMP INSTALLATION ❑ VZ" SYSTEM REPAIR ❑ OTHER ❑ f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _/s2 r DISPOSAL FLD. PROP. LINE 25t i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11 �T_ Dia. of Well Casing Domestic/Private KGravel Pack ❑ Tracy Type of Casing_?VC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1 101 Type of Grout ❑ Irrigation _,q pprox. Depth ❑ Eastern Surface Seal Installed by -1'11ifxu[lr , Repair Work Done ❑ Type of Pump H.P. State Work Done_�fr1Ya Well Destruction ❑ Well Diameter11 —�— Sealing Material (top 501 ___�lrflfT l�Z�y.E tii./f' caB T ' Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION CI DESTRUCTION ❑ INo septic system permitted if public sewer is -. Installation will serve: Residence_ Commercial_. Other available within 200 feet.) Number of living units:_ Number of bedrooms Character of soil to a depth of feet: Water table depth f SEPTIC TANK ❑ Type/Mfg. CapacityNo. 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 I SEEPAGE PITS ❑ 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, 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." Contractors 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 California." The applicant must all for all requjred inspections. Complete drawing on rr-ev'eer"see side. / / Signed Cr/�Z��, Title: Z_✓fdViF.Y cr.:h7 ,Date: �11� 2 FOR DEPARTMENT USE ONLY j Application Accepted by Date _ Area Pit or Grout Inspection by Date Zai Final Inspection by Data Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i ffE= D {nRECEIVED BY DATE PERMIT'NO. EH 1}y11BEV.1/X51 IIS V� %3i o �r EH 142 O