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NNW, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PA 1601 E. HAZELTON AVE., STOCKTON, CA ��C �D Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 21 1P90 (Complete in Triplicate) SAN JOA.0i-'; , NTY PUBLIC H.EALT4 tV S Application is herebymade to the San Joaquin Local Health District for permit to construct and/or insENVHd 1 ed lication is q p 0►lRfEMfI§ICL�n Q made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu ahons Joaquin Local Health District. ''tt 1 Job Address 44yy�Ir44 ��Y'S h1 Al Nva.- City 'g � Lot Size SSD rX Fs�, PM Mn Owner's Name C Y-X!N `.'D • USA Address 11,6USffl i Tx 11W Z Phone Contractor --�� - -- Address A` License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �, Spll V"V-Y- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLS-! 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 of Casing Specifications I'1 Public X Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation 1r�Approx. Depth DQ Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State n�ork Done'1_ Well Destruction ❑ Well Diameter Sealing Material (top 50'I Y.,nif�tn,+t PadEis er CCIMCIAt SIur'ry / Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 111 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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." 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 st all for all quire s coons. Complete drawing on reverse side`. 1,t � //�� T Signed X Title: �b+rGtVt ewtr.1 k-k'nx rttate: a.k V �/11,d/�� /I a FOR DEPARTMENT USE ONLY Application Accepted by r��9r Ql�/^^rp-C�-j R DEPARTMENT Date 1112 7 1U Area J Pit or Grout Inspection by drl"K„i`^t�' Date Final Inspection by_. / C Date Additional Comments: ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO . EH 1124(REV.1/951 :�') 10 EM 14-M