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VI il APPLICATION FOR PERMIT R ' J SAN JOAQUIN LOCAL HEALTH DISTRICT A 1601 E. HAZEL T ON AVE., STOCKTON, CA /tom OOT 15 1990 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NV'�i�ONIViCNTAI•�H, A�-� (Complete in Triplicate) RM(T 1 sERmCE Application is hereby madeto 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 �7Q� rv5�' City s7v - Lot Size Zoo )e SZ:o� PM Owner's Name AL08Address Phone Cpntractor �[! - /`f.4 Address'3a Q Sz License No. 601 18( Phone?1 - 7Z TYPE OF WELL/PUMP: NEW WELtSp< WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Mw, 164f15 wcdl DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES >11 00.�_.__ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom El Manteca Dia. of Well Excavation�C+ 2.or� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_4_IC. St- Specifications fD 1`7 Public F Other F Delta Depth of Grout Seal Type of Grout I 1 Irrigation .Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump N� H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is �4 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: S t_Nca. , Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Propeny.Line A S' LEACHING LINE ❑ No. & Length of lines Il)!4 Total length/size S FILTER BED ❑. Distance to nearest: Well Foundation Property Line - SEEPAGE PITS l I Depth Size /�� Number SUMPS ❑ 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 Di§trict. 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, l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for a required inspections. Complete drawing on reverse side. Signed X Title: ?='t�in�Z �Z��V�C'tL51 Date: VA 111 91D 4 FOR RT USE ONLY L Application Accepted by Date Uv Area Pit or Grout Inspection by Date W� Final Inspection byf/ Date i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Apniicant - Return all copies to: Environmental Health Permit/Services 1601 E. Haza(ton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-N& INFO (� /CLASH +.EH14-26-241REV.riH51 �� q 'Opt EH 14 ! 4