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APPLICATION FOR PERMIT ' } SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA } Telephone (209) 466-6781 U u P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 2 3 1989 (Complete in Triplicate) Tu Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the PQ r,- T II"llipplication is made in compliance with San Joaquin County Ordinance No.599 for sewage or No. 1862 for well/pump and the Rui� e� �g��h§lPtt a San Joaquin Local Health District. Job Address �+`9� J/l�'7 ��e - �4� - --- — City t z KG Lot Size PM Owner's Name -:; I' �0fkd4 Address 92 Rox lip Phone 5-_T/1 Contractor ra Address 'L 35 .f License No. TYPE OF W LL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER�.SOiLgaY%17fe}-� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open 8oitom ❑ Manteca Dia- of Wroib Excavation a Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications�j �"' ('I Public n Other I n Delta Depth of Grout Seal FJs Type of Grout7�eu«�fie►it +� I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by PdJfAr� ,r CaCC*)r VA Repair Work Done L]' Type of Pump 620AM- H.P. State Work Done __ 4 Well Destruction ❑ Well Diameter Sealing Material (top 501 NE 2/3 Depth Filler Material (Below 50')5 7A&6elf4" TYPE OF SEPTIC WORK: NEW INSTALLATI[ORN I I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 feet-) Installation will serve: Residence Commercial_ Other Q Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ( Method of Disposal ` Distance to nearest: Well Foundation Property Line i r LEACHING LINE ❑ No. & Length of lines Total length/size 1. ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line F� SEEPAGE PITS I I Depth rf Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 xI 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: "t 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." ''1 The applic st call for all required inspections. Complete drawing on reverse side. Signed Title: - �Wza r Date: 23 FO EPAR USE ONLY Application Accepted by Date � ragr' Pit or Grout Inspection b Date l V' � Final Inspection h / DateJ (Aires G(/�_ �- CSL c� 07� �.wr Additional Comments: 71 �,.,r. �. A?al?3-r ❑ Stk 466-6781 ❑ Loi 369-3621 ❑ Manteca 3-7109 ❑ Tracy 835-638 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 rCE 1 � INFO AMOUNT DUE t AMOUNT REMITTED SH RECEIVED BY Q DATE PERM11 NO. + EH 13.21[REVr/H5f ,�� C�_ 1/O ` 1 EH U�28 11 1 OC7