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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT n 1601 E. HAZE T ON AVE., STOCKTON, CA Y Telephone (209) 466-6781i + PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V)I (Complete in Triplicate) FEB 2 1990 Application is hereby made to 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 ffi lgRn�jp kl� gnlS�Pf�ihq San Joaquin Local Health District. J Job Address 303,570 S7_,VA rV 566/ City rAZIPS4Lot Size PM04 _ Owner's Name m c Address /VIC A)X �cZ�vZ. �i A3 A&1-4y phnno C 00 5 ti b hWr �..0. BOX 567 Contractdr .bft ' t9�. Address Ot fifr19i:bdTCitV# 'Co A003-License No. X63675 Phone(303) 286-77 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 03,j"&V11(o,t ,,,I/V PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Jcz,/,/ DISTANCE TO NEAREST: SEPTIC TANK M-Or_,� SEWER LINES DISPOSAL FLD.5— PROP. LINE l7rlf FOUNDATION AGRICULTURE WELL 0! OTHER WELL 0�� PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I_l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'FAC _ Specifications FI Public IAOther F1 Delta Depth of Grout Seal S Type of Grout--j�!nh-yA16 I I Irrigation '&70 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. — State Work Done _ Well Destruction ❑ Well Diameter L/ff Sealing Material (top 501 Depth /201 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 1 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: de 1 _ SEPTIC TANK L1Type/Mfg Capacity-0 Fmpart s PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number _ SUMPS 11 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 Dt%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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requi spections. Complete drawing on reverse side. Signed >r T c Title: Vice,zPresident Date:JanUary 30, 1990 FQWDEP ENT USE ONLY 2 C Application Accepted by 04 c4of4 f Date�7—/Jr�G Area 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 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT N0. EH EH 13 24(REV.1 i N 5) Q3 - T��,160 o S