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I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 :PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 11662--N. Ham Lune City Lot Size PM Owner's NameWSt_LarR 101t1P (JCMa� Address Phone 17754 N. Hwy. 88 Contractor Cbehri lq Pn _AddressLOCkef ord ,Ca. License No.309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIRU OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tt DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type 4f Cashel Specifications F1 Public n Other r F-1 Delta Depth of Gro Seal Type of Grout I I Irrigation Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State WorkiDorie R2l1IQVed 3HP & Instal 1ed Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth 4 Filler Material (B-,-1,-w-7-507,-,---' " -- TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION l I DLSTRUCTION;I"I (No septic system permitted if public sewer is \' I available within 200 feet.i �\ Installation will serve: Residence____ Commercial_ Other Number of living units: Number of bedrooms444 f Character of soil to a depth of 3 feet: .Water table depth �Q � SEPTIC TANK ❑ Type/Mfg Capacity- No. Compartments PKG. TREATMENT PLT. ❑ a t- _ Method of Disposal Distance to nearest: Well Foundation 1' Property Line LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well Foundation--Y_�—Property Line SEEPAGE PITS l I Depth Size Number _ SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 Di1trict. i 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 er as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I c f 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 c, f Ire ired inspections. Complete drawing on,reverse side. Signed X � Title: Bkpt^_ __ Date: 08/07/90 FOR DEPARTMENT USE ONLY / G� y �f I Application Accepted by S Date r��0 Area Pit or Grout Inspection by Dat_�e - - Fin I,lrispection by V �1M �� — Dat s j Additional Comments: i ❑ 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 95201i r�A r,:ii r ; FEE AMOUNT DUE AMOUNT REMITTED C S RECEIVED BY DATE PERMIT'NO. INFO f /� � r.EH 13-24[HEV.t/R 51 vl �L/ EH 14-29 i .- � f