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. f 1r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT s )Q�QUIN LOCAL HEALTH DISTRICT' 1601 E. HAZEL T ON AVE., STOCK XNMENTAL HE/.!_ i: DIVISION Telephone (209) 466-6781 - PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) SAN PA MIN LO C'ITH i +1 1-I� ISTRICC yyy�� TI{ V1510N Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ itRaw MRMln applicatiori is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and San Joaquin Local Health District. +��■ t Job Address lam/ v ?!�n 4 City Lot Size PM Owner's Nam LI C,A"C' T44"'_ Address �T /-� �7'00V Phone 6J Contractor "'� Address �/ /c� �4 License No�a�Phone31,7—f'023 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ YSTEM REPAIR El OTHER I? ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI RE WELL OTHER WELL PITS/SUMPS j i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CJ ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing— 0 Specifications /Yo�� f'1 Public �?'9ikrerdq�]ir f-1 Delta Depth of Grout Seal Type of Grout _ I I Irrigation / Approx. Depth I I Eastern Surface Seal Installed Repair Work Done ❑ Type of Pump U b'A H,P. VZ State Work Doneor Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is available within 200 feet.I RCS 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 ppa(M6 TF is PKG. TREATMENT PLT. LJ RR4et�to� df spoEsaI Distance to nearest: Well Foundation Property Line_ LEACHING LINE ❑ No. & Length-of lines Total iength/size FILTER BED ❑ Distance to nearest: Well Foundation___-__4N\11R0HMWYAL HEALTH RVICES SEEPAGE PITS i l Depth Size Number SUMPS ❑ 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: "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 t call for re re inspections. Complete drawing on reverse side. Signed X Title: � d Date: 3-sr-89 FOR D ENT S ONLY Application Accepted by �7 c� Date Atea Pit or Grout Inspection by yy]�-rte. Date�/�l'JL Final InspeccttiioLn why / _e�Date Additional Comments:fs6-/iiy7 s/K-�40"& "//�i�[.C& IJ PJ-/—:A4 a" ®G//Jl ;PTY &!=51?D ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Writeca 823-7104 O Tra4 835-6385 �1yo 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 K RECEIVED BY BATE PERMIT'NO. ♦.EH1 -24lREV.1/H5) � _ FH 144-28 �