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f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 NIO�oar�VG�P► PERMIT EXPIRES 1'YEAR FROM DATE ISSUED OCT 7 1988 �J (Complete in Triplicate) ENVIRONMENTAL:HEAI_T9 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo JjQryondghis application is made in compliance with San .loaquin-Cou -Ordinance-No._549 for sewage_,or_No..,1862 for well/pump and the Rt an AAg''u''�Ta�Zi''o''n``s'o the San Joaquin Local Health District. L-A) # Job Address 8006-, 1z City - Lot Size PM Owner's Name '.0d $/(1- CW- /1/ )9 7 Address F00 5, 0.*Vkee Zane , LOA' Phone 2017 36 a 27J Contractor ( �CTRy�-1 bK XL/#r r+ddress 217 '1 YRTL License No. V 224F _Phone Zffl O I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Z(or`{'oeas ..� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Vg4M ITM DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4Q ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12JOp Dia. of Well Casing 4 4 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i5ck%•4o Specifications CC'morir tote.. f M Public 1-1 Other Ll Delta Depth of Grout Seal Type of G out 5-90 t eMcwt' I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed byJF bSt+►6S f Repair Work Done ❑ Type of Pump H.P. State Work Done_ i Well Destruction ❑ Well Diameter Seating Material (top 501 CeOA19itf W 3-76 UKbrkdP— Reft'Ebt WE",X Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i l DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet/ Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I i 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 L-t 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 District. 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 itis issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantst call for quir inspections. Complete driving on reverse side. i " Signed j L r e: Date: f0_& FOR DEPARTMENT USE ONLY Application Accepted by Date,NJ_ 'r'7�"C/ Area Pit or Grout Inspection by Date Final Inspection by Date I SAN JOAQUIN LOCAL HEALTH DISTRICT � Additional Comments: INJVI ❑ Stk 466-6781 El Lodi' a racy 835 5 'j��} Applicant - Return all copies to: Environ,52 101 E. Hazelton Ave., P.O. Box: Stk., CA 9 1 �%�� FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO lq + EH 13-241REV.IIH al � i; v� u�� EH 14-26 { _I