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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ) �� 1601 E. HAZELTON AVE., STOCK CA �Ij Telephone Q09) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED G,PR 09 1991 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework I Illi licanon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rulus 4J��1)CT�San Juaqum Local Health District. r Job Address __...1_"l Hee/rCity CPP Lot Size PM �h Jas vlr C01T.1 Z2Z, �, 464,or 94'f-36 7 7 Owner's Name Address Phone �I' �y 6330 & we+' Rd. Contracts ' ' 'crlary '-"• a�r04 Address 81 g License No. Phone' qw-2,7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION LI PUMP INSTALLATION 0 SYS�T/EM REPAIR 0 OTHER 0 _DISTANCE TO NEAREST: SEPTIC TANK �/�11 SEWER LINES t141— DISPOSAL FLD SIM u PROP. LINE lAh-Pwh FOUNDATION 1A l4h AGRICULTURE WELL" OTHER WELL PITS/SUMPS�p h~1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 Ll Industrial 0 Open Bottom 0 Manteca Dia. of Well Excaevatio Dia. of Well Casing -_ fl Domestic/Private Ll Gravel Pack Ll ack 0 Tracy Type of Casing .Stir. �{1 . P� Specifications o I I'I Public XOthef vionadbrlh6 Delta Depth of Grout Seal � '- �� Type of Grout 7 C I I Irrigation __-Approx. Depth✓✓ I I Eastern Surface Suet Installud by Repair Work Done 11 Type of PumpH.P. rSState Work Done_ Well Destruction Cl Well Diameter, Sealing Material (top 50') 49?wl� Depth Filler Material (Below 501 50a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l 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 CI Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines _ Total length/size FILTER BED Ll Distance to nearest: Well Foundation_. Property Line SEEPAGE PITS I I Depth Size _—____ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 17 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local Health DI'3trict. Home owner or licensed agent's signature certifies the following: "I cenify 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 canities the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compunsa tion laws of California." The applica 2t st call for all rARquire z pe tions. Complete drawing on reverse side. L 9 1Signed x Title: �C'r- I);Ic,G L, Date: __... jZoy I • WPS NC Ilty Application Accepted by _— Data 4 5 Jt� Area _ Pit or Grout Inspection by Dat Final Inspection by Date Additional Comments: - 0 Stk 466-6781 0 Lodi 369-3621 O Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 NFEE FO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII NO. • CH�4 IREV.vnh� gc-� .e,o gcl ao ►�L� / �n� '�-{ G -C11