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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT P/a►YiVIEIT 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone I209I 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 14 1989 {Cornplete in Triplicate? 14kkR00#MeW1 f�hiH i on is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew an Joaquin • made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an�ftml�ty�+Lc,# III l Local Health District. � !�� Job Address City�,qw� - Lot Size 1144M�Ir 5 PM � Zd �83 -•/O Owner 8J�-&4a c [0 r� 's Name Address Contractor� Address 32 33 fa 6CRs�l.10 License No.55 7 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �oFt►r►�1! f'p's 7Y DISTANCE TO NEAREST: SEPTIC TANK DGU r SEWER LINES 56C. DISPOSAL FLD._A%a-94F-PROP. LINE 2_L09 FOUNDATION AGRICULTURE WELL (OTHER WELL �`� tfl`�1P PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ D Dia. of Well Casing d ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation_ Specifications ❑ Domestic/Private ❑ Gravel Pack 10 Tracy Type of Casing �C", ZType of �ro!'1 Public fl Other Cl Delta Depth of Grout Seal 4 I I Irrigation eb!Approx. Depth l I Eastern Surface Seal Installed by SRL"" Repair Work Done ❑ Type of Pump 11,14--- H.P. - VL-1 — State Work Done — �,. r,, 1 Sealing Material (top 50'1 �1 "'t' �! "-'�-"+ Well Destruction ❑ Well D4er �-�f�. g SDepth Filler Material (Below 50'1 'TYPE OF SEPTIC WORK: NEWLLATION I I REPAIRIADDiTION I I DESTRUCTION I I aNailsepttiable w shin system rmit►ud it public sewer is Installation will serve: Residence *ed e sal_ Other r Number of living units: Nroo } Water table depth • Character of soil to a depth of 3 te SEPTIC TANK ❑ Type/ Capacity No. Compartments Do Method of Disposal PKG. TREATMENT PLT. Distan : lFoundation Property Line LEACHING LINE 0 No. & es Tota!fengthlsixe Pro a LineFILTER BED ❑ Distan : Well Found tion Property nn SEEPAGE PITS I I Depth Size Number l' SUMPS LI Distance to nearest: Well Foundation Property Line 1. � U 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 DiMrict. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, l shall not l employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature n 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 II required inspections. Complete drawing on reverse side. Title: 9!1ErZ Date: Signed FOR TMENT USE ONLY Date Area k Application Accepted by Pit or Grout Inspection by� Date Final inspection by Date r i Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3Ei9 3621 ❑ Manteca -7104 ❑ Tracy 835-6385 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Applicant - Return all copies to: Environmental Health Permit/Services r 1 1 FEE CK RECEIVED BY DATE PERMIT ND. AMOUNT DUE AMOUNT REMITTED SH INFO I1 + EH 11241REV.1/1451 '35. W