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APPLICATION FOR PERMIT w R SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. _HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 0 9 4989 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install.tPEALT110N application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and Ft San Joaquin Local Health District. ENVIONMENTAL Job Address QFIYC t CAMPJ1��i_L 4, ,r� City STO t o Lot Size PM Owner's Name C1 © �W Address C!r y It-g. Phone Of ^8 Contractor SPrC_T � d- Address 25 5 M RZZ 6 STLicense No.-;U ?_ 8 _Phone ZG TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER fi�So � 13C2+q/6,S f Al P•v/TOQiK(r {(,ter 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 I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation + 1 Dia. of Well Casing 7.5 Domestic/Private gavel Pack © Tracy Type of Casing sc 10 VG Specifications z C-9�_4 6 hl l`l Public FI Other f�Delta Depth of Grout Seal .�10 Type of Grout r I 1 Irrigation 45-1 Approx. Depth I 1 Eastern Surface Seal Installed by S)?EGTPU^A FxPL _ Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 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 ❑ 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 Di$trict. 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 this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica must all for all required inspe ns Complete drawing on reverse side. ��ice- 13 Z.( Signed X Title: G<, �fil`� tMQ Date: 51Z190 0 p^� J 1� pt FOR DEPARTMENT USE ONLY Application Accepted by ( �.-r.CzLC.. _ -- Date ? /Area '� q Pit or Grout Inspection by Date Final Inspection by 6 1/ '' "`t , Date J . t / Additional Comments: o t. f I"-L VI0" "`` "i z � G ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 3-7104 ❑ 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 REMITTED K H RECEIVED BY DATE PERMIT-NO. INFO . EH la-24 4REV.t/w si 7 2 �- 0 cl O 7 //aho '� O EH 14-26 J .7 �,