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r 4 APPLICATION FOR PERMIT f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Sari 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. } STOCITpN 4 1/2 ac Job Address 55u5 _E 17JAIN ST City Lot Size PM Owner's Name FRELD !' T - Address f 5 U� E MkiN Phone 931-1825 Contractor, r 1 AddressP License Na. 7'� Phone 1' ....L!_ TYPE OF•WELL/PUMP: . NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INS TION SYSTEMLREPAIR ❑\, OTHER ❑ DISTANCE TO-NEAREST_: SEPTIC TANK20a -I- SEWER LINES L7�.' -r 011 P'' 'L FLD. PROP. LINE2_15feeu t FOUNDATION N y =A`GRICULTURE-WELL--- ---OTHER WELL~"""`—PITS-/SUMPS- r ONTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1industrialLJ Open Bottom L] Manteca- - Dia. of Well Excavation Dia- of Well Casing 3n i 6,Domestic/Private -Gravel Pack ❑ Tracy ? ' Type of Casing=M Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal 1''J Type of Grout Cement C� 11 Irrigation --Approx. Depth it Eastern St�Hace Seal Installea`by I f.R r Repair Work Done Ll Type of Pump SI»� H.P. ' z` tState Work Done_ `�1 r # ( Well Destruction ❑ Well Diameter Sealing Material (top 50'1 I Y C„ T I1 Depth -� Filler Material (Below 50'1 ("�1 j TYPE OF SEPTIC WORK: NEW.INSTALLA_TION I I REPAIR/ADDITION I I ; DESTRUCTION I I INo septic system permitted if public sewer is `V available within 200 feet,-)} r ' Installation will serve `Residence Co r ercial„ Other t �` Number of living units: ' � Nur�ber of bedrooms ( Character of soil to a depth of 3'feet`.°""'" °i Water table depth SEPTIC TANK ❑a Type/Mfg Capacity . _ No. Compartments PKG. TREATMENT PLT. ❑ j Method of Disposal Distance.to.nearest:--Well- Foundation*n' eProperty Line LEACHING LINE A0 Le No. &' ngth of lines Total length/size �*., s•. .' ,�r FILTER BED ❑ Distance to nearest: Well `� "*` �6undetion_ Property Line t SEEPAGE PITS 11 Depth Size Number e SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ iI 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 a ,rules and regulations of the San Joaquin Local Health District. Home owrler 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." 4 The applicant must call for all re wired inspections. Complete drawiHd on`reverse"eide T , ; l M-M'UT'ER �� 2-26-89 Signed X—___ _ Title: • Date: FOR DEPARTMENT USE ONLY ` �. .Application Accepted by w, �= Date 27 Area c� f s o�. -.Z 2Q Final Inspection by Date-1, Pit or Grout inspection by _ Date � p -! Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ©':Manteca a23-7104..%, ` ❑ Tracy__,'836-6385'^, w Applicant - Return all copies to: Environmental Health Permit/services 1661 E`Heze)ton Ave ,P.Q. Box 2009, Stk., CA 95201 FEEt INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. ♦ EH 13-24iREV.1'95) /,9 S 5, �7� < �+ EH 14-26 �UOJ 1 -37