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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON , CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAY 1 5 1989 ( Complete in Triplicate) SAN JOAQUIN COUNTY P�f LIC H LTH SERVICES Application is hoteby made to the San Joaquin Local Health District for a permit to construct and/or '�I�' �I I �ry�y � phF��sfy� r) h?ppltcation is made in compliance with San Joaquin County Ordinance No. 599 for sewage or No. 18(12 ler well/punt,z':hTr�'I SRnflus Al 117Sjulahinhs o Iho San Joaquin Local Health District . 1 Jab Address 4U /0 Fa.51 Fr4e Ml6VL_I City %cnK4w%� Lot size PM PbOwner's Name ` b st, Address ��_ a8�- -- Phone tot CA Ci nhaclor _ Address 17 _U�IY� !Liamse Nu. .�7�_ Pilot) TYPE OF_W_EL_L/ PUMP: NE WELL _ WFLL REPLACEMENT I I DES1l1UCrION I I / PUMP INSTALLATION CI SYSTEM REPAIR 11 OTHER.FJ' /e �✓ • 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 LlIndustrial CI� �Open Bottom I I Manteca Dta. of Well Excavation _ Dia. of Well Casing I I Domestic/ Private IWGravel Pack IA Tracy Type of Casing .__sIm" — stU pVt�- Specifications I ' I Public I 1 Other Il Delta Depth of Grout Seal Typo of GroutM7 _ 6^{/c�. iu anon �p � Approx. Depth I I Eastern Surface Seal Installed by 'r�.,QyAJ1Ars�,_R _—__--___ . . Ahxp� fit o� OVoikt Don I I Type of Pump H . P. ___ — --_—_ State Work DoneKom Well Destruction C] Well Diameter _ Sealing Material ( top 501 Depth Filler Material IHulow 50' ) TYPE OF SEPFIC WORK : NEW INSTALLATION I I HEPAIR / ADDITION I I DLSTIlt1CTION I I ( No suptic system pernaucd it pul) ic sower is available within 200 leet . l C 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 ..__ I, SEPTIC TANK (A Type/Mfg - Capacity__ __ No. Compartments _ PKG. TREATMENT PLL ❑ Method of Disposal _ Distance to nearest: Well Foundation __.. ..-. ._—_ Properly Line i' LEACHING LINE Cl No. & Length of lines Total length/size _ IN FILTER RED ❑ Distance to nearest: Well __— Foundation _ __ ......___ Properly Line SEEPAGE PITS I I Depth Size ___ ___ __— Number SUMPS I I Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS I -] 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 DiEbict . Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, 1 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 i canities the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all required inspections. Complete drawing on reverse sit ij jEAJlDfL Y �OLOL ( S % Signed X 2. �.LLSIry� Title: L4� CT 0 $ Data: 9 F EP ENT USE ONLY T i! Application Accepted by �j Date — Are �/�'' / Pit or Grout Inspection by Date 60 G� Final Inspection Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/ Servicas 1601 E. Hazelton Ave„ P. O, Bax 20090 Slk. , CA 95201 f INFO AMOUNT DUE AMOUNT flEMITTEO ASII flECEIVEO HV DATE PERMIT NO. [7 . EH t}N IflEV. hrxnh EN 13 20