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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL'HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 �1AY 1 r 9989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOA.LJIN COUNTY (Complete in Triplicate) - HE SERVICES Application is hereby made to the San Joaquin Local Health District for a permit to C011Srn1Ct anrf/or install'111d ��1t'H 'Zted."1q E{ �tinn is made in compliance with Sari Joaquin County Ordinance No. 549 for sewage or No. 11162 for well/pump and the Rules and Hegulaiions of the San Joaquin Local Health District, I Job Address 2040 SCity t'� ' LE.ot Size PM / Q i Owner's Name Address A-- , r t — 7 f l C ✓J — ` Phone 4 Contract _ dtlress SQ_oOW�.6_S�ff�_ S � 7z `+� License No._GJ = ._F'lionef� YZ TYPE OF WELL/PUMP: NEW ELL WELL REPLACEMENT I I DESTRUCTION I I PUMP INSTALLATION ❑ _ SYSTEM REPAIR L) OTHER ❑ 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE: TYPE OF WELLW PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ;t rl Industrial Cl Open Bottom 1-1 Manteca Dia. of Well Excavation �� Dia.'of Well Casing 2 F. Domestic/Private i�erravel Pack !_I Tracy Type of Casing 'SLH % II3 W! Specifications ^�i !'1 Public I-1 Other (-I Delta Depth of Grout Seal � Type of Grout-VJW- J(fj_llWAU I e IIll,annn �Approx. Depth E I Eastern Surface Seal Installud by Repai 1.>1eAon, e_�1 Type of Pump H.P. _ _TState Work Done Well Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material {Below 50') -- 1YPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIHIADDITION i I DEESIHUCTION I 1 IN() supric syslum penuiltud it public sewer is available within 200 feet.) (1 Installation will serve: Residence_____ Commercial Other.___� lVrl Number of living units: —_ Number of bedrooms T Character of soil to a depth of 3 feet: table depth SEPTIC TANK f_1 Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line — LEACHING LINE I No. & Length of lines Total length/size _ FILTER BED 11 Distance to nearest: Well— Foundation _ _ Property Line SEEPAGE PITS 13 Depth Size ___ ____.—_ Number_ SUMPS LI Distance to nearest: Well Foundation - Property Line V DISPOSAL PONDS is I hereby certify that I have prepared this application and that the work will be clone 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 this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applican must call for all squired inspections. Complete drawing gn reverse rdo Signed X e"I 0� g Title: G�UQL.-[�_ Date: r L FORD ME ONLY Application Accepted by Date re � Pit or Grout Inspection b Date.._ — Final Inspection by Additional Comments: D Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I--] Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE l INFO AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED'BY DATE PERMIT NO, i EH 13-24 INEV.1/M E. 90—/ ! EH 1426 //