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r_ APPLICATION r0m PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -0. Telephone 12091 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED APR 09 1991 ' (Complete in Triplicate) ppl. t' Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worrcNhe VIRO HEAblj�ation is made in compliance with San Joaquin County Ordinance No.549 for sewage pr No. 1862 for well/pump and the Rules an �an Juaq urn Local Health District. cv' Job Address �' Y`^ N City 5-foa71 24 Lot Size PM Sart oa ar Cope 222 6- S�iW-3677 Owner's Name q n Address Phone F b330 'yr* �Rdt � Contraclor AII-Terrain ` P/M� nAddfegs rb CA L-icense No. Phon,691 99/-2199 TYPE OF WELL/PUMP: NEW WELL J1 S WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM '�REPAIR ❑ ��/O��THER ❑ DISTANCE TO NEAREST: SEPTIC TANK a✓>7 SEWER LINES (`�atJVl DISPOSAL FLD1(aEl. PROP. LINE V 401VA FOUNDATION ul1 AGRICULTURE WELLUakRatrn OTHER WELL akrwwn PITS/SUMPS "Nl+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_C1I. 90 FVCSpecifications VI Public A otper MON)'W1 1Q n Delta Depth of Grout Seal "'7 Type of Grout rc I I Irrigation a .Approx. Depth) I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump n H.P. State or Done_ L_ Well Destruction ❑ Well Diameter �- Sealing Material Itop 50'1 SCI fr�ekt &II& AAWd Depth h' Filler Material (Below 50'1 —,QBd TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 x PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 Di1hict. 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 nor 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 call for all re ctio s. Complete drawing on!!=side. SignedX L Title: /f=G'�✓/1�1611 I Dpte: f r t� i Application Accepted byWONLY �r�� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 17 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, Silk., CA 95201 FEE INFO �'A"MOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE ^PERMIT'NO. • ER 13.241REV.rrxsr C cci 00 �� '0� I'lO rn � L� � .Ct f ( /i�y� EN 14 78 u 1 I` II L