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APPLICATION FOR PERMIS SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Com late in Triplicate) PAYMENT RECEIVED APR 17 1990 V SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the ft# k MoerpKENiMication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well /pump and 101 h4914!1#eAf TIfNIA3' Naquin Local Health District. Address SanV City 10C Ort Lot Size lot) Y 360 PM _� Job _('' %C& 3707 K1nSs L04 t# � P 0- �� %f 16) 7 Owner's Name V Address J20.[t , PhoneC1 C�e 3S"��`` 7..7 f 4e? 1,&7U,)L Phone 'J Contractor 6Jt011 Address (AC se No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER''jk vpfe6ie DISTANCE TO NEAREST: I SEPTIC TANK NIA SEWER LINES SUI DISPOSAL FLD.EA PROP. LINE FOUNDATION 201 AGRICULTURE WELL _&OL OTHER WELL_ PITS/SUMPS )—JM INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation x — Dia. of Well Casing e ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing hone Specifications M Public ..� Ll Other Cl Delta Depth of Grout Seal Type�of Grout f _ I I Irrigation &- Approx. Depth I I Eastern Surface Seal Installed by r e S _ Repair Work Done ❑ Type of Pump H. P. State Work Done _ Ee Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 YP� E OF SEPTIC WORK: NEW INSTALLATION I I REPAIR /ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation wi l _ Other Residence _ Co�bedrooms Number of living units: r of Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundata'0i0�� Property Line LEACHING LINE ❑ No. & Length of lines Total length ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line_'"'_T SEEPAGE PITS 1 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 applicanst call for al qu' ed inspections. Complete drawing on reverse side. /�� r,o Signed X s2 rQ h t i Title: E6w heer- Date: �• m^ � � ('l to OR DEPARTMENT q ENT USE ONLY Gp Application Accepted by<4Date S / 19a Area 3 23 Pit or Grout Inspection by Date Final Inspection by 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 ♦. EH 13-24 (REV. 1/ 9 5) EH 14-2a FEE AMOUNT DUE TED ED AMOUNT REMIT - CK CASH RECEIVED BY DATE PERMIT* NO. # -3 3S"��`` x/33 V Ar. -'o 0 - /07p 77