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_4 APPLICATION FOR PERMIT J SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT } Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1'YEAR FROM DATE ISSUED MAR 14 1989 (Complete in Triplicate) p J R00#M 7�hif ,"gon is Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the T , made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welt/pump and the Rules antya'tis�Tbe an Joaquin Local Health District. IIC Job Address City p rti Lot Size 1114 N"If 4PM ' Owner's Name 12AA Address Z g Phone2e :�_AO j 9 K Contractor awI Address 32 S A042 4--/414W License No.SS :7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER 9 t.3oaf'^'1( ,4�s 7i' DISTANCE TO NEAREST: SEPTIC TANK (GoI r SEWER LINES ��p, DISPOSAL FLD. A"' PROP. LINE �pU es FOUNDATION i �a� AGRICULTURE WELL f�.z07'rtOTHER WELL 5`Y PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ID industrial ❑ Open Bottom [_1Manteca Dia. of Well Excavation /4 Dia. of WeA Casing ❑ Domestic/Private ❑ Gravel Pack IV Tracy Type of Casing d6wPOREM& Af Am Specifications t 1-1 Public F1 Other ❑ Delta Depth of Grout Seal 40 .5- .4e Z Type of I I Irrigation a !-Approx. Depth ( I Eastern Surface Seal Installed by is Repair Work Done ❑ Type of Pump V1T.-.- H.P. VL 10 State Work Done_ I Well Destruction ❑ Well Diam er ��A Sealing Material Itop 501 �A4- Depth Filler Material (Below 501 to-k-_A4-- C4_s� �>� / '�' "'t TYPE OF SEPTIC WORK: NEW IN TALLATION 17 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is ]]] t available within 200 feet.1 Installation will serve: Residence�k Cojhder.- ial_ Other Number of living units: Number of _L Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 111-n PKG. TREATMENT PLT. ❑ Method of Disposal W Distance to nearest: I Foundation Property Line �+I jt i LEACHING LINE ❑ 'No. & Lengt lines Total length/size u� FILTER BED ElDistanc_-,o nearest: Well Found tion Property Line .I J SEEPAGE PITS l 1 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 G 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 Di'Wict. 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: '9 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." l I The applicant must call far 11 required inspections. Complete drawing on reverse side. Signed X g&4r Title:C� �y W#4W 4 �'�4 Date: J- 97 FOR TMENT USE ONLY Application Accepted by -�= `" Date �' Area ? Pit or Grout Inspection by� Data � Final Inspection by DatecJy� 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 AMOUNT DUE AMOUNT REMITTEDINFO C SH RECEIVED BY DATE' PERMIT'NO. ,�q\� J f � p r.EH 13-24 MEV.1185) c7b v� -N-S)`/ EH 14-26