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w _ J APPLICATION FOR PERMIT E SAN JOAQUIN LOCAL HEALTH DISTRICT D� 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 NOV 10 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEEENVI ONMENTAL HEqLN (Complete in Triplicate) 'PERMiTISERVICIES 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 Rules and Regulations of the San Joaquin Local Health District. Job Address .n, 1 S%.')A I City� � Lot Size PM Owner's Name y 17ir t V M r,Tll Address Phone Z016 3 y,,., i Contractor (r� , na./ ,Address �OQ� J 11V License No.° f� Phon 0& TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ {, . DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ><Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications } M Public C1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by _ Repair Work Done ElType of Pump, - ^H.P: �� State Work Don 7 CJ Well Destruction CI Well Diameter Sealing Material {top 501 Depth Filler Material (Below 50'1 ""- TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRIADDITION I 1 DESTRUCTION I i INo• ��y tted if public sewer is ; ova it O elt.1 Installation will serve: Residence Commercial— Other ; t dErVi1 Number of living units: Number of bedrooms # ' ^ Apy 0Q 4v�i -- Character of soil to a depth of 3 feet: 1 [!Water t lei! SEPTIC TANK ❑ TypelMfgCapacity— Icfir* PKG. TREATMENT PLT- p �N QMj_ i 4 ES f Distance to nearest: Well Foundation Property Line f A jDiVI.CjQN LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS I 1 Depth r Size = .Number. - SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL PONOS ❑ 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 r rules and regulations of the San Joaquin Local Health District. T Home owner or licensed agent's signature certifies the fotwing: "I certify that in the performance of the work for which this permit is issued, I shall note 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 requ'.a ins joctions. Complete drawing on reverse side. Signed X–)& Title: 0 n A Zia Date: PARTiMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date` i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1323-7104 ❑ Tracy 835-6385 ; Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 FEE INFO AMOUNT DUE AMOUNT REMITTED K H RELVE ED BY DATE PERMIT-NO. t EH 13.24 IREV.1 i H 51 J EH 14-26 Y