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r_ 4 ` APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT y � PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 1 5 1989 j (Complete in Triplicate) SAN JOAQUIN COUNTY P LIC 'H?LTH SERVICES cation is Application is hereby made to the San Joaquin Local Health District for a permit to construct an J/ INLIC ogu a I Pp made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1R62 for well, f��y g e{1u atrons o the San Joaquin Local Health District. �('� 1 e L0SO Ea5 + re �� City "' Lot Size PM Job Address � -- �fa� i Owner's Name +��?L Address �_ � Phone Contractor Address _�E ice'nSI No. t4_4J-7_+!_Phan � S)_ = TYPE OF WELL/PUMP: NE WELL W WELL REPLACEMENT I DESTRUCTION Il / PUMP INSTALLATION ❑ SYSTEM REPAIR CI OTHER. /e- DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE j ~� FOUNDATION AGRICULTURE WELL OTHER WELL_—..— PITS/SUMPS= INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS t► �� fl Industrial L�I O�pen Bottom LI Manteca Dia of Well Excavation _ Dia. of Well Casing ❑ Domestic/Private tw ravel Pack ill Tracy Type of Casing.__�_,rn._ �? Specifications 1 1'I Public IV- other f-1 Delta Depth of Grow Seal _^'�1_ ._—__` Type of Grout l _CA.W.1_ �u it SSG Approx. Depth I I Eastern Surface Surd Installed by_ TE, RepamWofklDonf_t] Type of Pump _ H.P. ____r _-- State Work Done`_ --_ Well Destruction 0 Well Diameter __. Sealing Material Itop 501 Depth Filler Material iBelow 601 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I E STRUCTION I 1 (No saptir: system penninu,l it public sewer is n available within 200 fuel.) l' 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 epth_.__SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal R` Distance to nearest: Well Foundation _ -_ -�_ Property Line LEACHING LINE ID No, & Length of lines �_.__-.__.—_Total length/size.- _ 14 FILTER BED 1_1 Distance to nearest: Well� - Foundation __. _____ Property Line SEEPAGE PITS I } Depth Size _ --- Ntimhor SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I'] • 0 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 applicant must call for all required inspections. Complete drawing on reverse idy,p _p S if��A6 ,-- Signed X t — Tit la: WC% & !�6 1 L Date: ' F EP ENT USE ONLY Application Accepted by Date Are Pit or Grout Inspection by Date v — Final Inspection r' i Date v Additional Comments: 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. INFO CASH • EH 13-24 IREV.,i n!,, e o ; - 7 — elcl nrQ"t2 as EH,4.26