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i I APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I - aA; 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r y i (Complete in Triplicate) ,. Application is'hereby made to the San 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. Job Address _ 7�7 rt Pe�t i 'Rd- City Lind6n Lot Size PM Owner's NameT.i nr7an TTn i$i gar] SrhridlArTdr tit 18-92 7 R. Main _ Phone $87"' 600 Linden: Ca 95236 Gontract Address P• 0• BOX 64,'; ,Llrider�icense No. 377923 Phone 887-3554 I` TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION Z SYSTEM REPAIR LlOTHER VC replacement DISTANCE TO NEAREST: SEPTIC TANK-""!i SEWER LINES DISPOSAL FLD. PROP. LINE �J FOUNDATION -'f AGRICULTURE WELL OTHER WELL—,PITS/SUMPS i - I i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation .Dia. of Well Casing F ❑ Domestic/Private 11 Gravel Pack 0 Tracy Type of Casing- Specifications X Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑Eastern Surfbce Seal Installed by Repair Work Done ❑ Type of Pump SL b H.P. 7-1-hp! - State Work Donereplaoed G ell Destruction ❑ Well Diameter Sealing Material (top 591 E Depth Filler Material (Below 50') TYPE OF-SEPTIC-WORK:--NEW INSTALLATION ❑ REPAWADDITION'❑ DESTRUCTION ❑ (No septic system permitted if public sewer i `ff available within 200 feet.) Installation will serve: Residence— Commercial-%ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth L SEPTIC TANK 17 Type/Mfg Capacity No. Compartments ,PKG. TREATMENT PLT- ❑ J * Method of Disposal i� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length-of-lines Total-Iengtti7size' FILTER BED ❑ Distance to nearest: Well Foundation Property Line :SEEPAGE PITS ❑ Depth Size Number u 6UMP-5 - -. ❑ Distance.to.nearest, —Well Foundation Property Line ---� -- - 11DISPOSAL 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[his permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." " l I The p icarA call for e� red spections. Complete drawing on reverse side. signed a </z Title: COVD Secretary Date: 5/22/87 FOR DEPARTMENT USE ONLY Application Accepted by - Date Area 0 'Pit or Grout Inspection by " Date Final Inspection by Date `Additional Comments: 4 ❑ Stk 466-6781. 0,L6di •369-3621 i Y �p Marteca_� 823=7104 ❑ Tracy 835-6385 ,Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 IE! INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. +EH;&25 EV.I/ a 5I �Q EH f1428 ��....••JJJ Y